Standardization of electronic medical records data in rehabilitation
10.3969/j.issn.1006-9771.2025.01.003
- VernacularTitle:康复电子病历数据标准化研究
- Author:
Yifan TIAN
1
;
Fang XUN
1
;
Haiyan YE
1
;
Ye LIU
1
;
Yingxin ZHANG
1
;
Yaru YANG
2
;
Zhongyan WANG
2
;
Meng ZHANG
2
;
Xiaoxie LIU
2
;
Yanyan YANG
2
;
Bin ZENG
2
;
Mouwang ZHOU
3
;
Yuxiao XIE
4
;
Guangxu XU
5
;
Jiejiao ZHENG
6
;
Mingsheng ZHANG
7
;
Xiangming YE
8
;
Fubiao HUANG
9
;
Qiuchen HUANG
10
;
Yiji WANG
11
;
Di CHEN
1
;
Zhuoying QIU
2
Author Information
1. Department of Rehabilitation Information Research, China Rehabilitation Science Institute, Beijing100068, China
2. Rehabilitation Medicine and Health Management Center, Gaozhou People's Hospital, Maoming, Guangdong525200, China
3. Department of Physiotherapy, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing100068, China
4. WHO-FIC Collaborating Center in China, Beijing100068, China
5. School of Social Development/International Center for Rehabilitation Policy and ICF Research, University of Health and Rehabilitation Sciences, Qingdao, Shandong266113, China
6. Peking Union Medical College Hospital, Beijing100730, China
7. Xizang Autonomous Region Rehabilitation (Care) Center for Persons with Disabilities, Lhasa, Xizang 850000, China
8. Beijing Municipal Center of Healthcare Quality Control and Improvement in Rehabilitation Medicine, Beijing100191, China
9. Department of Rehabilitation Medicine,Guangdong Provincial People's Hospital of Southern Medical University (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong510080, China
10. Department of Rehabilitation Medicine, China-Japan Friendship Hospital, Beijing100029, China
11. The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu210029, China
- Publication Type:Journal Article
- Keywords:
rehabilitation;
electronic medical records;
data standards
- From:
Chinese Journal of Rehabilitation Theory and Practice
2025;31(1):33-44
- CountryChina
- Language:Chinese
-
Abstract:
ObjectiveTo explore the data standard system of electronic medical records in the field of rehabilitation, focusing on the terminology and coding standards, data structure, and key content categories of rehabilitation electronic medical records. MethodsBased on the Administrative Norms for the Application of Electronic Medical Records issued by the National Health Commission of China, the electronic medical record standard architecture issued by the International Organization for Standardization and Health Level Seven (HL7), the framework of the World Health Organization Family of International Classifications (WHO-FICs), Basic Architecture and Data Standards of Electronic Medical Records, Basic Data Set of Electronic Medical Records, and Specifications for Sharing Documents of Electronic Medical Records, the study constructed and organized the data structure, content, and data standards of rehabilitation electronic medical records. ResultsThe data structure of rehabilitation electronic medical records should strictly follow the structure of electronic medical records, including four levels (clinical document, document section, data set and data element) and four major content areas (basic information, diagnostic information, intervention information and cost information). Rehabilitation electronic medical records further integrated information related to rehabilitation needs and characteristics, emphasizing rehabilitation treatment, into clinical information. By fully applying the WHO-FICs reference classifications, rehabilitation electronic medical records could establish a standardized framework, diagnostic criteria, functional description tools, coding tools and terminology index tools for the coding, indexing, functional description, and analysis and interpretation of diseases and health problems. The study elaborated on the data structure and content categories of rehabilitation electronic medical records in four major categories, refined the granularity of reporting rehabilitation content in electronic medical records, and provided detailed data reporting guidance for rehabilitation electronic medical records. ConclusionThe standardization of rehabilitation electronic medical records is significant for improving the quality of rehabilitation medical services and promoting the rehabilitation process of patients. The development of rehabilitation electronic medical records must be based on the national and international standards. Under the general electronic medical records data structure and standards, a rehabilitation electronic medical records data system should be constructed which incorporates core data such as disease diagnosis, functional description and assessment, and rehabilitation interventions. The standardized rehabilitation electronic medical records scheme constructed in this study can support the improvement of standardization of rehabilitation electronic medical records data information.
