Analysis on Common Written Mistakes and Causes for Error of Inpatient Medical Records in Traditional Chinese Medicine / 世界科学技术-中医药现代化

ABSTRACT

Medical record writing is a basic skill for clinicians. As to traditional Chinese medicine (TCM) record, practice writing for a good record can help young TCM doctors to build up the thinking of diagnosing and treating diseases in the unique way of TCM. Being a TCM resident for six years, I find young TCM doctors do not pay enough attention to the medical record writing, producing many common mistakes in the record, which young doctors do not even realize that they are making mistakes everyday in their inpatient medical records. Main mistakes are as followsthe solar term of disease attack is appointed as the term of the day patients are hospitalized; in order to satisfy the disease and syndrome diagnosis, doctors would rather make up a fictitious symptom rather than using the patient’s real chief compliant; the history of the present illnesses are always written too short and ambiguous, which cannot reflect the whole course of the onset, development and changes of illness from its occurrence to the time that the pa-tient comes to the doctor;the presenting symptom is written as the name of the symptom, without descriptive details, which cannot reflect TCM characteristics;nearly all diseases are written as“illness with unknown cause”according to western medicine, ignoring TCM pathogenesis;patient's personal history is written similar to each other, and pa-tient's emotions, diet preference is missing, which should vary with each individual;the four diagnostic methods and TCM syndrome differentiation of the everyone’s illness are written all the same, generally according to the text-book; TCM treatment plan is not made according to TCM disease / syndrome diagnosis in the medical record. The main cause of these mistakes in the inpatient department of TCM hospital has been westernized too much by western medicine. Young TCM doctors can use as much of western medicine as they want;and they use more western medi-cine than TCM in the inpatient department, which weakens their TCM skills. Many TCM doctors in inpatient depart-ment do not focus on practicing TCM four diagnosis skills, such as tongue and pulse, and they do not know how to use the four diagnostics;and do not exactly know how to make a syndrome differentiation either. Thus, they diagnose and treat diseases with western medical thinking instead of considering TCM thinking. When writing a medical re-cord, they tend to copy TCM diagnosis according to textbooks instead, but do not make an authentic TCM diagnosis by themselves, lacking critical thinking skills for TCM. Furthermore, TCM record writing standards made by the Ministry of Health and TCM are defective in reflecting TCM characteristics, which has misguided many doctors. The last reason is that doctors tend to make false entries in medical records in anticipation of medical audits. There are still other outside pressures such as quick treatment of excess patients and liability, which cause errors above. TCM will bestamped outif attention is not paid to this.