Abstract
Objective The medical record of Chinese medicine is a miniature of the theoretical system of traditional Chinese medicine (TCM), with a time-honored history in a real-world setting and a firm place in medicine. In modern times, people have emphasized the value and standardization of TCM cases. The aim of this study was to explore the historical origins and developments of TCM case records. Methods A chronological narrative style was used to divide the development history of TCM case records into early (1600 BC–220 AD), middle (220–1911 AD), and modern periods (1912–till now). The historical context of the origin and development of TCM case records was analyzed through the evolution of the format and content of the case recording files with the specific documents and distinctive cases. Results From the early to middle period, the development of TCM case record had experienced four periods: the budding, blossoming, maturity, and heyday. In modern times, they presented the following characteristics: A, the establishment and development of the discipline of TCM medical records; B, the standardization of the writing format of TCM medical records; C, a large number of books concentrating on recording and studying TCM medical records, especially those of prestigious veteran TCM doctors; D, the proliferation of TCM case reports published in journals; E, the establishment of TCM medical records databases and application platforms integrating computer programs and artificial intelligence; F, many reporting guidelines have been developed in order to improve the reporting quality of case report in TCM. Conclusions The study analyzed and illustrated the characteristics of TCM case records of different dynasties in terms of writing content and format. TCM case record is a relatively young discipline in spite of its ancient origins. TCM case records still have far-reaching significance for the inheritance and development of TCM theory and clinical experience. From the wisdom of history, its positive impact has just been revalued to be validated and it will continue to develop.
Highlights
On the issue of terminology in this study, “case record” is used extensively in various aspects, whereas “case report” is used exclusively in modern medical journals
Case report refers to a detailed description and formal summary of a diagnostic or therapeutic problem experienced by one or several patient(s), such as exposure, symptoms, signs, interventions, and outcomes [1, 2]. e early case records in the west can be found in the ancient Egyptian medicine papyrus records from about 1600 BC [3,4,5]
The case report is a particular form of clinical evidence despite the low-ranking evidence level in the modern evidence hierarchy [6]
Summary
On the issue of terminology in this study, “case record” is used extensively in various aspects, whereas “case report” is used exclusively in modern medical journals. Cang Gong, named Chunyu Yi (215-167 BC), was the only physician going down in history in the Western Han Dynasty [25] He was the first to record clinical cases through personal observations with the motivation to evaluate the percentage of successes and failures and find a guide for future predictions. In the Jin Dynasty, Liu Wansu started to study the Plain Questions (Su Wen) at the age of 25 He took the “nineteen articles of pathogenesis” of Plain Questions as the theoretical basis, systematically classified diseases according to the five evolution phases and six climatic factors (Five Yun and Six Qi), analyzed the etiology of diseases, and combined his clinical experience and academic thought to explore the inner connection between causes and symptoms, and put forward his own insights in diagnosis and treatment methods.
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