Please wait a minute...
Traditional Medicine Research  2016, Vol. 1 Issue (1): 43-51    DOI: 10.12032/TMR201601006
Orginal Article     
Similarities and Differencesof Doctor-Patient Co-operated Evidence-Based Medical Record of Treating Digestive System Diseaseswith Integrative Medicine Compared with Traditional Medical Records
BoLi1,2, Wen-HongShao3, Yan-DaLi3, Ying-PanZhao1,2, Qing-NaLi1,2, Yang Zhao1,2, CaiShang Hong4,*()
1Xiyuan Hospital, China Academy of Chinese Medical Sciences Drug Clinical Trial Institution Beijing, China.
2China Academy of Chinese Medical Sciences Institute of Clinical Pharmacology, Beijing, China.
3Beijing United Family Hospital and Clinics (BJU), Beijing, China.
4Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing, China.
Download: HTML     PDF(229KB)
Export: BibTeX | EndNote (RIS)      

Objective:To establish the model of doctor-patient cooperated record, based on the concepts of narrative evidence-based medicine and related theories on Doctor-Patient Co-operated Evidence-Based Medical Record.Methods:We conducted a literature searchfrom Pubmed, following the principles of narrative evidence-based medicine, and refer to the advice of experts of digestive system and EBM in both traditional Chinese medicine and Western medicine.Result:This research is a useful attempt to discuss the establishment of doctor-patient co-operated evidence-based medical record guided by narrative evidence-based medicine.Conclusion:Doctor-patient co-operated medical record can become a key factor of the curative effect evaluation methodology system of integrated therapy of tradition Chinese medicine and Western medicine on spleen and stomach diseases.



Key wordsEvidence-based medicine      Narrative medicine      Therapeutic evaluation      Integrated therapy     
Published: 15 November 2015
Corresponding Authors: CaiShang Hong     E-mail: shanghongcai@foxmail.com.
About author:

Executive Editor: Cui-Hong Zhu

English Editor: Lin Li, Li-Yun-Cui, Ya-Song Wang, Xiao-Hua Zhang, Xiao-Dong Wang, Hong-Xu Zhu, Zhen-Yan Liu, Yi-Cheng Shi

Cite this article:

BoLi, Wen-HongShao, Yan-DaLi, Ying-PanZhao, Qing-NaLi, Yang Zhao, CaiShang Hong. Similarities and Differencesof Doctor-Patient Co-operated Evidence-Based Medical Record of Treating Digestive System Diseaseswith Integrative Medicine Compared with Traditional Medical Records. Traditional Medicine Research, 2016, 1(1): 43-51. doi: 10.12032/TMR201601006

URL:

https://www.tmrjournals.com/tmr/EN/10.12032/TMR201601006     OR     https://www.tmrjournals.com/tmr/EN/Y2016/V1/I1/43

After one month’s treatment, I feel that… (Please tick on the items you agree with.)
1At least two persons said I look goo 1sure 2something like that 3none
2I think I look good 1sure 2something like that 3none
3I feel strength all over the body 1sure 2something like that 3none
4At least two persons think I’m vigorous when doing things 1sure 2something like that 3none
5At least two persons think I’m not so irritable 1sure 2something like that 3none
6I think I’m in good mood 1sure 2something like that 3none
7At least two persons said I eat more than before 1sure 2something like that 3none
8I think I eat more than before 1sure 2something like that 3none
9At least two persons said I had accept TCM treatment 1sure 2something like that 3none
10I accept TCM treatment 1sure 2something like that 3none
11At least two persons think I complain less of pain 1sure 2something like that 3none
12I feel that there are fewer symptoms. 1sure 2something like that 3none
 
Cardinal Symptoms Category Grades
Pain in the upper abdominal (gastral cavity) Nature 1swelling pain 2dull pain 3burning pain 4stabbing pain 5other
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 serious
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week5almost everyday

Distention and Fullness the upper abdominal (gastral cavity)
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 serous
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week5almost everyday

Oppression in the upper abdominal (gastral cavity)
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 severe
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week5almost everyday

Sour regurgitation
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 serious
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week5almost everyday

Heart burn
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 serious
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week 5almost everyday

Belching
Time 1before meal 2after meal 3before and after meal 4other
Degree 0none 2mild 4 moderate 6 serious
Frequency 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
0never 11less than one day a week 2one day a week 32-3day a week 44-5day a week5almost everyday
Table 1 Clinical symptoms observation: Cardinal Symptoms.
Appetite decrease 0none 1mild 2obvious 3total have no appetite
Food-intake decrease 0none 1less than 1/3 2 1/3-1/2 3more than 1/2
Belching 0none 2occasionally 4sometimes 6most of the time 8 during the whole day
Burning sensation in substernal 0No 2Yes Pain in substernal 0No 2Yes
pharyngeal foreign body sensation throat 0No 2Yes Prefer warmth and pressure in stomach 0No 2Yes
Nausea 0No 2Yes Distending pain in the chest and hypochondrium 0No 2Yes
Vomiting 0No 2Yes Pain in abdominal 0No 2Yes
Dry in the mouth 0No 2Yes Abdominal distention 0No 2Yes
Bland taste in the mouth 0No 2Yes Vexation and irritable 0No 2Yes
Bitter taste in the mouth 0No 2Yes Hard breath and weak statement 0No 2Yes
Sticky sensation in the mouth 0No 2Yes Fatigue 0No 2Yes
Halitosis 0No 2Yes Oppression in the chest 0No 2Yes
Hunger without appetite 0No 2Yes Feverishness in palms and soles 0No 2Yes
Fear of coldness 0No 2Yes Cold in limbs 0No 2Yes
Lassitude in limbs 0No 2Yes Poor sleep 0No 2Yes
Yellow urine 0No 2Yes Emaciation 0No 2Yes
Table 2 Clinical symptoms observation: Minor symptoms.
Inducing and aggravating factors of main symptoms Category
Having meal 0No 1Yes
Empty stomach 0No 1Yes
Tiredness 0No 2Yes1Yes
Having a cold 0No 1Yes
Medical factors 0No 2Yes1Yes
Climatic variation 0No 1Yes
Emotional factors 0No 2Yes1Yes
Intense work and high pressure 0No 1Yes
Others
Table 3 Clinical symptoms observation: Inducing and aggravating factors of main symptoms.
Symptoms for differentiation reference Category
Defecation times time(s) every day(note: fill in with 1/n if the patient defecate once every couple of days)
Texture of stool 1well-formed soft stool 2dry 3watery 4dry and watery now and then
Tongue body 1red 2reddish 3pale 4other
Tongue coat 1yellow greasy 2white greasy 3white thin 4other
Pulse 1slippery 2string-like 3other
Table 4 Clinical symptoms observation: Symptoms for differentiation reference.
Symptom making me suffer most and their duration (months)
Other symptoms making me suffer and theirduration (months)
Objective of clinical visit 1understand disease;2relieve symptoms;3restore health;4avoid relapse;5other
Diagnosis and Treatmentsatisfaction 1very satisfied ;2satisfied;3ordinary;4dissatisfied;5extremely dissatisfied
Reason of satisfaction 1treatment effect;2doctor’s attitude;3medical visit experience;4other
Goal hoping to achieve 1have definite diagnosis of western medicin or TCM with name and TCM pattern; 2 symptoms relieved 50% above; 3seizure frequency decresed 50%;4other
Free description:
Table 5 Patient’s record.
No. Items Never Occasionally Sometimes
Most of the time

All the time
1 Are you easy to be tired? 0 1 2 3 4
2 Do you sleep well? 0 1 2 3 4
3 Do you have feeling with no hunger in meal time? 0 1 2 3 4
4 Is your appetite decreasing? 0 1 2 3 4
5 Do you want to eat, but dare not to eat? 0 1 2 3 4
6 Do you feel dry in your mouth? 0 1 2 3 4
7 Do you taste bitter? 0 1 2 3 4
8 Do you have bad breath? 0 1 2 3 4
9 Do you have foreign body sensation at your pharynx? 0 1 2 3 4
10 Do you have sour regurgitation? 0 1 2 3 4
11 Do you hiccup or belch? 0 1 2 3 4
12 Do you feel nausea? 0 1 2 3 4
13 Have you vomited? 0 1 2 3 4
14 Do you have burning sensation in substernal? 0 1 2 3 4
15 Are you painful in substenal? 0 1 2 3 4
16 Do you feel pain in stomach? 0 1 2 3 4
17 Do you feel distending in stomach? 0 1 2 3 4
18 Do you feel burning in stomach? 0 1 2 3 4
19 Do you feel pain in abdomen? 0 1 2 3 4
20 Do you feel distending in abdomen? 0 1 2 3 4
21 How is your pain in substernal? 0 1 2 3 4
22 How is your burning sensation in substernal? 0 1 2 3 4
23 How is your pain in stomach? 0 1 2 3 4
24 How is your feeing of distending in stomach? 0 1 2 3 4
25 How is your pain in abdomen? 0 1 2 3 4
26 How is your feeling of distending in abdomen? 0 1 2 3 4
27 Do you have diarrhea? 0 1 2 3 4
28 Do you have constipation? (defecate more than every 3 days, or have dry and hard stool or have difficulty in defecating) 0 1 2 3 4
29 Do you still want to defecate after having done it? 0 1 2 3 4
30 Do you feel urgent to defecate (Do you rush to the wash room)? 0 1 2 3 4
31 Have you lost weight in recent 2 months? 0 1 2 3 4
32 Is your mood affected easily? 0 1 2 3 4
33 Are you in anxiety or tension? 0 1 2 3 4
34 Are you worried about your disease? 0 1 2 3 4
35 Does your health condition limit your social activities such as shopping or visiting relatives or friends? 0 1 2 3 4
36 Dose the disease affect your status or role in family or work? 0 1 2 3 4
37 Patient’s signature Date
38 Physician’s signature Date
Table 6 PRO’s Evaluated Table of Gastroenteropathy.
After one month’s treatment, I feel that… (Please tick on the items you agree with.)
1At least two persons said I look goo 1sure 2something like that 3none
2I think I look good 1sure 2something like that 3none
3I feel strength all over the body 1sure 2something like that 3none
4At least two persons think I’m vigorous when doing things 1sure 2something like that 3none
5At least two persons think I’m not so irritable 1sure 2something like that 3none
6I think I’m in good mood 1sure 2something like that 3none
7At least two persons said I eat more than before 1sure 2something like that 3none
8I think I eat more than before 1sure 2something like that 3none
9At least two persons said I had accept TCM treatment 1sure 2something like that 3none
10I accept TCM treatment 1sure 2something like that 3none
11At least two persons think I complain less of pain 1sure 2something like that 3none
12I feel that there are fewer symptoms. 1sure 2something like that 3none
Table 7 The comprehensive evaluation one month after cooperating.
1.   Atkins D, Best D, Briss PA, et al.Grading Quality Of Evidence And Strength Of Recommendations. BMJ, 2004, 328(7454): 1490.
2.   Schunemann H, Fretheim A, Oxman AD.Improving The Use Of Research Evidence In Guideline Development: 10.Integrating Valuesand Consumer Involvement. Health Res Policy Syst, 2006, 4:22.
3.   Fletcher SW, Spitzer WO.Approach Of The Canadian Task Force To The Periodic Health Examination. Ann Intern Med, 1980, 92(2 Pt 1):253-254.
doi: 10.1097/00000441-198005000-00008 pmid: 7352732
4.   Glasziou P, Chalmers I, Rawlins M, et al.When Are Randomized Trials Unnecessary? Picking Signal From Noise. BMJ, 2007, 334(7589):349-351.
5.   Thompson DC, Rivara FP, Thompson R. Helmets For Preventing Head And Facial Injuries In Bicyclists. Cochrane Database, Syst Rev,2000; (2): CD001855.
6.   Oxman AD, Guyatt GH.Guidelines For Reading Literature Reviews. CMAJ, 1988, 138(8): 697-703.
7.   Cannegieter SC, Rosendaal FR, Briet E.Thromboembolic And Bleeding Complications In Patients With Mechanical Heart Valveprostheses. Circulation, 1994, 89(2): 635-641.
doi: 10.1161/01.CIR.89.2.635 pmid: 8313552
8.   Karanicolas PJ, Davies E, Kunz R, et al.The Pylorus: Take It Or Leaveit? Systematic Review And Meta-analysis Of Pylorus-preserving Versus Standard Whipple Pan Creaticoduodenectomy For Pancreatic Orperiampullary cancer. Ann SurgOncol, 2007, 14(6): 1825-1834.
9   9.[9]Schunemann HJ, Jaeschke R, Cook DJ, et al. An Official ATS Statement: Grading The Quality Of Evidence And Strength Of Recommendations In ATS Guidelines And Recommendations. Am JRespirCrit Care Med, 2006, 174(5): 605-614.
10.   Guyatt G, Cook D, Devereaux PJ, et al.Therapy. In: Guyatt G, RennieD, eds. The Users’ Guides To The Medical Literature: A Manual For Evidence-based Clinical Practice. Chicago: AMA Publications, 2002.
11.   Montori VM, Devereaux PJ, Adhikari NK, et al.Randomized Trials Stopped Early For Benefit: A Systematic Review. JAMA, 2005, 294(17):2203-2209.
doi: 10.1001/jama.294.17.2203 pmid: 16264162
12.   Wang Yongyan,Shang Hongcai,Mu Wei Wang Yanping and ect. Strengthen The Theory Of Medical Humanities And Embrace The New Medical Reform And Study Narrative Medicine In Modern Traditional Chinese Clinical,Ⅴo1 22 No 1 Jan:1-4
13   13.CHARON R.Narrative Medicine:From, Function, And Ethics[J]. Annals of Internal Medicine, 2001,134(1):83-87
14   14.CHARON R.Narrative Medicine -A Model For Empathy, Reflection, Profession, And Trust[J] JAMA,2001,286(15):1897-1902.
15   15.Wang Yifang Clinical Medical Humanities: Problems and Solutions - On The Significance Of Narrative Medicine For Clinical Humanities [J⒈ Medicine and Philosophy, 2013,34(9A):. 14-18.
16   16.Liu Fengbin, Wang Weiqiong, Formulate PRO’s Evaluated Table On Stomach Disease And Item Selection [J]. The World Science And Technology (Modernization of Traditional Chinese Medicine), 2009, (4).
17.   Wang P, Tang XD, Liu BY, Zi MJ.Development of a patient-reported outcome instrument for chronic gastrointestinal disease :item selection. J Chin Integr Med. 2012: 10(10):1092-1098.
pmid: 23073192
18.   Tang XD, Wang P, Liu BY, Zi MJ.Development and Analysis of a Patient Reported Outcome Instrument for Chronic Gastrointestinal Diseases. Journal of Traditional Chinese Medicine. 2008:50(1):27-29.
[1] Li Bo, Tian Gui-Hua, Gao Rui, Zhao Ying-Pan, Li Qing-Na, Zhao Yang, Shang Hong-Cai. Under the narrative medicine theory to establish the evidence-based medical record written by doctors and patients through integrated therapy of traditional Chinese and western on digestive system diseases[J]. Traditional Medicine Research, 2017, 2(2): 80-87.