病历书写是临床医生的基本功，中医病历的书写，对于青年中医师培养形成中医思维尤为重要。笔者通过亲身经验，发现在中医住院病历书写中，存在很多约定俗成的错误，违背了病历客观、真实、准确的原则。常见问题有：发病节气默认为入院当日所属节气；主诉不能真实客观反应病情；现病史不能体现疾病演变及诊疗过程；中医刻诊所见症状缺乏所属特征；“无明显诱因”成为所有疾病的病因；个人史不能因人而异；中医四诊信息照搬西医或套用模板；中医辨病辨证分析流于形式；中医治疗方案与病历脱节。出现上述问题的主要原因是由于住院中医西医化，很多青年医师逐渐失去中医望闻问切基本技法，没有锻炼形成中医辨证的思维逻辑，在书写病历时形成思维定势，致使中医病历普遍西医化。卫生管理部门制定的病历书写规范存在缺陷，一定程度上也误导了临床医生，导致病历书写错误。此外，临床医生为了迎合各项检查，按照诊疗规范书写病历，常常伪造中医住院病历的中医信息，导致中医病历千篇一律。%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 follows:the 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 be"stamped out"if attention is not paid to this.
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