Standardization of outpatient medical record in rehabilitation setting
10.3969/j.issn.1006-9771.2025.01.004
- VernacularTitle:康复门诊病历数据标准化研究
- Author:
Ye LIU
1
;
Qing QIN
2
;
Haiyan YE
1
;
Yifan TIAN
1
;
Yingxin ZHANG
1
;
Yaru YANG
3
;
Zhongyan WANG
3
;
Meng ZHANG
3
;
Xiaoxie LIU
3
;
Yanyan YANG
3
;
Bin ZENG
3
;
Mouwang ZHOU
4
;
Yuxiao XIE
5
;
Guangxu XU
6
;
Jiejiao ZHENG
7
;
Mingsheng ZHANG
8
;
Xiangming YE
9
;
Fubiao HUANG
10
;
Qiuchen HUANG
11
;
Yiji WANG
12
;
Di CHEN
1
;
Zhuoying QIU
3
Author Information
1. School of Rehabilitation Medicine, Nanjing Medical University, Nanjing, Jiangsu210029, China
2. Huadong Hospital Affiliated to Fudan University, Shanghai200040, China
3. Rehabilitation Medicine and Health Management Center, Gaozhou People's Hospital, Maoming,Guangdong525200, China
4. Department of Physiotherapy, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing100068, China
5. Department of Rehabilitation Information Research, China Rehabilitation Science Institute, Beijing100068, China
6. Department of General Office, China Rehabilitation Science Institute, Beijing100068, China
7. School of Social Development/International Center for Rehabilitation Policy and ICF Research, University of Health and Rehabilitation Sciences, Qingdao, Shandong266113, China
8. Xizang Autonomous Region Rehabilitation (Care) Center for Persons with Disabilities, Lhasa, Xizang 850000, China
9. Peking Union Medical College Hospital, Beijing100730, China
10. Beijing Municipal Center of Healthcare Quality Control and Improvement in Rehabilitation Medicine, Beijing100191, China
11. National Center for Healthcare Quality Management in Rehabilitation Medicine, Beijing100191, China
12. Department of Rehabilitation Medicine, Guangdong Provincial People's Hospital of Southern Medical University (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong510080, China
- Publication Type:Journal Article
- Keywords:
rehabilitation outpatient medical records;
standardization;
data sharing
- From:
Chinese Journal of Rehabilitation Theory and Practice
2025;31(1):45-54
- CountryChina
- Language:Chinese
-
Abstract:
ObjectiveTo analyze the data structure and standards of rehabilitation outpatient medical records, to provide data support for improving the quality of rehabilitation outpatient care and developing medical insurance payment policies. MethodsBased on the normative documents issued by the National Health Commission, Basic Standards for Medical Record Writing and Standards for Electronic Medical Record Sharing Documents, in accordance with the Quality Management Regulations for Outpatient (Emergency) Diagnosis and Treatment Information Pages (Trial), reference to the framework of the World Health Organization Family of International Classifications (WHO-FICs), the data framework and content of rehabilitation outpatient medical records were determined, and the data standards were discussed. ResultsThis study constructed a data framework for rehabilitation outpatient medical records, including four main components: patient basic information, visit process information, diagnosis and treatment information, and cost information. Three major reference classifications of WHO-FICs, International Classification of Diseases, International Classification of Functioning, Disability and Health, and International Classification of Health Interventions,were used to establish diagnostic standards and standardized terminology, as well as coding disease diagnosis, functional description, functional assessment, and rehabilitation interventions, to improve the quality of data reporting, and level of quality control in rehabilitation. ConclusionThe structuring and standardization of rehabilitation outpatient medical records are the foundation for sharing of rehabilitation data. The using of the three major classifications of WHO-FICs is valuable for the terminology and coding of disease diagnosis, functional description and assessment, and intervention in rehabilitation outpatient medical records, which is significant for sharing and interconnectivity of rehabilitation outpatient data, as well as for optimizing the quality and safety of rehabilitation medical services.
