Research Article

History and Development of TCM Case Report in a Real-World Setting

Table 4

The main structure and elements of the format standard of TCM case records from the 5 monographs.

Representative booksStructure and elements

Biography of Bian Que and Cang GongPatient’ name, home address, profession, name of disease and name of TCM pattern, main complaint, pulse condition, etiology, pathogenesis, syndrome differentiation, diagnosis, treatment, and prognosis

Han’s Medical TreatmentDate of consultation, place, height, weight, face color, voice, disease condition, disease location, etiology, the onset time and the aggravated time of illness, afraid of cold or heat, diet, the previous treatment history, pulse condition, manifestation and root cause of disease, diagnosis, severity of illness, treatment method, prescriptions, medication methods.

Essence of Pulse TheoryDate of consultation, place, patient’s name, age, height, weight, face color, voice, the main symptoms and signs, the onset time and the aggravated time of illness, disease condition, the previous treatment history and clinical effects, nature of yin or yang, afraid of cold or heat, diet, sleep condition, pulse condition, name of disease, name of TCM pattern, manifestation and root cause of disease, chronic or acute, treatment method, diagnosis, prescriptions, the modification of prescription, the explanation of Chinese medicine and prescriptions, contraindication, the doctor’s signature.

Experience of Chinese MedicineDate of consultation, place, patient’s name, age, height, weight, face color, voice, emotions, disease condition, etiology, the onset time and the aggravated time of illness, the main symptoms and signs, the present symptoms, the previous treatment history and clinical effects, afraid of cold or heat, diet, excretory functions, sleep condition, pulse condition, manifestation and root cause of disease, treatment method, diagnosis, prescriptions, composition of Chinese herbs, analysis of illness, analysis of treatment, clinical effect.

Eight Requirements to TCM Case Record and Case Report by He Lian-chenPatient, name of disease and name of TCM pattern, etiology, TCM pattern, diagnosis, treatment principle, prescriptions, treatment outcomes.

TCM: traditional Chinese medicine.