中医医案报告规范的思考与建议  

Considerations and recommendations for Chinese medicine case report guideline

作　　者：王静[1] 吴力群[2] 马雪颜 刘铁钢[1] 董斐[1] 王洋[1] 骆长永 于河[1] 谷晓红[1] WANG Jing;WU Liqun;MA Xueyan;LIU Tiegang;DONG Fei;WANG Yang;LUO Changyong;YU He;GU Xiaohong(Beijing University of Chinese Medicine,Beijing 100029,P.R.China;Dongfang Hospital,Beijing University of Chinese Medicine,Beijing 100078,P.R.China)

机构地区：[1]北京中医药大学,北京100029 [2]北京中医药大学东方医院,北京100078

出　　处：《中国循证医学杂志》2021年第11期1347-1352,共6页Chinese Journal of Evidence-based Medicine

基　　金：国家重点研发计划项目(编号:2018YFC1704100,2018YFC1704101);北京中医药大学教育科学研究专项课题(编号:XJZX17004)。

摘　　要：中医医案是记录医家之经验心得、诊疗过程、指导后学继承和发展中医的特殊载体。它承载了大量的医学与人文信息,对中医学的发展起承前启后的作用,是一种被广泛接受、记录和传播中医文化的文体。随着大数据信息时代的到来,中医医案报告数量随之增多,但没有报告规范的指导,撰写和发表的医案报告质量难免良莠不齐,不能很好地指导或应用于临床实践和研究。通过对国内中医医案报告及规范的梳理并对国际相关报告规范的研究,本文讨论和分析了中医医案报告规范制定的必要性、存在问题并提出对策建议,促进中医医案报告撰写标准化工作的推进。Chinese medicine case report,a special method,records the experience of practitioners and guides students to inherit and develop Chinese medicine.It can transfer a large amount of medical and humanistic information and contribute to the development of Chinese medicine.It is a literary style that has been widely accepted and helps to document and disseminate the culture of Chinese medicine.With the advent of big data and information,more Chinese medicine case reports have been published.However,many have insufficient quality to properly guide and apply in the clinical practice,which might be caused by little guidance of Chinese medicine case report standards published.This paper summarized the case report standards,synthesized and appraised the feasibility and problems specific for improving the quality of Chinese medicine case reports,and proposed suggestions and guidance for developing the standardization of Chinese medicine medical case reports.

关 键 词：中医 医案报告 报告规范 

分 类 号：R249[医药卫生—中医临床基础] R-03[医药卫生—中医学]