希腊中医医师对病历记录方式的优选法——一项针对病历记录分级方法和普通病历记录的比较性调查研究

Chinese medicine case history taking using grading method, case history recording preferences amongst Chinese medicine therapists in Greece

关键词:  调查  诊断  病历记录  中医

Key words:  survey  diagnosis  medical record  Chinese medicine

摘要:

[目的] 通过比较普通中医病历记录和病历记录分级方法,探索中医病历记录的新方法,以促其完善和革新。[方法] 运用对比问卷调查的方法,调查对各类健康问题的诊疗情况,确定病历记录分级方法的临床使用情况。[结果] 研究初始共邀请705位医师参与调查,最终有69位(9.7%)参与,其中61位(8.6%)完整参与调查全过程。参与者首先学习病历记录分级方法,并将其应用于临床工作中至少2周。96.7%的参与者认为病历记录分级方法简单易学且使用方便,对患者复查及治疗方法的准确选择都有很大帮助;72.1%的参与者认为该法对于医生之间的沟通交流较普通病历记录更加有意义;57.3%的参与者决定在调查结束后继续使用该方法。[结论] 调查结果表明现代病历记录方法能够得以进一步完善与革新,这种通过对症状等的病历记录分级方法值得推广和应用。

Abstract:

[Objective] Find ways of improving the case recording guidelines. Compare the common procedure of history recording with the history recording that integrates a grading method. [Methods] A survey was conducted in Greece from February 2014 to April 2014, in order to explore the importance of the grading method in the patient's case history recording, amongst therapists treating patients by means of Chinese Medicine(CM). [Results] Out of 705 CM therapists that were asked to be involved in this research, 69 participated (9.7%) and 61(8.6%) successfully completed the procedure of the survey. Participants had to be educated into history taking grading method and use it for two weeks for all of their history records. 96.7% of the participants found the grading method easy to use, more useful for the re-evaluation of the patients than the ordinary CM case history and more useful for choosing the right treatment. The 72.1% of the participants believed that the case history with the particular grading method was more useful than the ordinary CM case history for their communication with other therapists. The 57.3% of the participants stated that they will continue using this grading method in their process of history taking. [Conclusion] This survey indicates that today's CM case history taking can be further improved, especially through methods such as symptoms and signs grading methods.