体征要素与体征术语规范化  

Standardization of Elements and Terms of Physical Signs

作　　者：王志国[1] 赵汉青[1] 卢鹏飞[1] 

机构地区：[1]中国中医科学院中医临床基础医学研究所诊疗信息化研究室,北京100700

出　　处：《世界中医药》2014年第8期1096-1098,共3页World Chinese Medicine

基　　金：科技部基础性工作专项资助(编号:2008FY230500)

摘　　要：体征要素是指抛开体征术语所包含的病位部分所剩下的关于身体某部位相对于先前正常状态下的异常变化,是以"有形""实体"为特征的客观存在,要素以多部位都可能发生的共性因素为要点。体征要素的提取能起到提纲挈领、执简驭繁、不易遗漏等作用,部分体征要素在治疗方面也存在共性,成为异病同治的依据。体征术语规范化有助于病历书写规范化,有助于诊断标准规范化,有助于学术交流和信息检索。体征术语规范化要求术语系统、准确、全面、完整、实用。体征术语的规范将通过发病部位+体征要素+体征清单的方式,采取中西并举,学科统筹,部位分类为主的方案加以解决。The elements of physical signs are the abnormities of certain parts of body excepting pathologic parts included in the existed terms of physical signs.They are characteristics of“materiality”,“substantiality”,existing objectively.The elements are the common factors possibly occurring in some parts of body.The pick-up of elements plays a role in concentrating on the main points,solving the difficult in a simple way and not being omitted easily.Some elements have much in common in treatment,becoming foundations of trea-ting different diseases in a similar way.Standardization of the terms of physical signs contributes to standardization of writing case histo-ry.It also benefits diagnosis criteria,academic exchange and information search.It requires being systematic,accurate,comprehen-sive,complete and practical.It can be achieved by the way of pathologic parts,elements of physical signs and list of physical signs,a-dopting the schemes of integrating TCM with Western Medicine,making overall plans in different subjects and classifying parts of body.

关 键 词：体征 体征要素 规范 

分 类 号：R229[医药卫生—中医基础理论]