Structure, content and data standardization of inpatient rehabilitation medical record summary sheet
10.3969/j.issn.1006-9771.2025.01.005
- VernacularTitle:康复住院病案首页结构、内容和数据标准化研究
- Author:
Haiyan YE
1
;
Qing QIN
2
;
Ye LIU
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:
inpatient medical record summary sheet;
data standardization;
International Classification of Diseases;
International Classification of Functioning, Disability and Health;
International Classification of Health Interventions
- From:
Chinese Journal of Rehabilitation Theory and Practice
2025;31(1):55-66
- CountryChina
- Language:Chinese
-
Abstract:
ObjectiveTo explore the standardization of inpatient rehabilitation medical record summary sheet, encompassing its structure, content and data standards, to enhance the standardization level of inpatient rehabilitation medical record summary sheet, improve data reporting quality, and provide accurate data support for medical insurance payment, hospital performance evaluation, and rehabilitation discipline evaluation. MethodsBased on the relevant specifications of the National Health Commission's Basic Norms for Medical Record Writing, Specifications for Sharing Documents of Electronic Medical Records, and Quality Management and Control Indicators for Inpatient Medical Record Summary Sheet (2016 Edition), this study analyzed the structure and content of the inpatient rehabilitation medical record summary sheet. The study systematically applied the three major reference classifications of the World Health Organization Family of International Classifications, International Classification of Diseases (ICD-10/ICD-11, ICD-9-CM-3), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), for disease diagnosis, functional description and assessment, and rehabilitation intervention, forming a standardized terminology system and coding methods. ResultsThe inpatient rehabilitation medical record summary sheet covered four major sections: inpatient information, hospitalization information, diagnosis and treatment information, and cost information. ICD-10/ICD-11 were the standards and coding tools for admission and discharge diagnoses in the inpatient rehabilitation medical record summary sheet. The three functional assessment tools recommended by ICD-11, the 36-item version of World Health Organization Disability Assessment Schedule 2.0, Brief Model Disability Survey and Generic Functioning domains, as well as ICF, were used for rehabilitation functioning assessment and the coding of outcomes. ICHI Beta-3 and ICD-9-CM-3 were used for coding surgical procedures and operations in the medical record summary sheet, and also for coding rehabilitation intervention items. ConclusionThe inpatient rehabilitation medical record summary sheet is a summary of the relevant content of the rehabilitation medical record and a tool for reporting inpatient rehabilitation data. It needs to be refined and optimized according to the characteristics of rehabilitation, with necessary data supplemented. The application of ICD-11/ICD-10, ICF and ICHI Beta-3/ICD-9-CM-3 classification standards would comprehensively promote the accuracy of inpatient diagnosis of diseases and functions. Based on ICD-11 and ICF, relevant functional assessment result data would be added, and ICHI Beta-3/ICD-9-CM-3 should be used to code rehabilitation interventions. Improving the quality of rehabilitation medical records and inpatient rehabilitation medical record summary sheet is an important part of rehabilitation quality control, and also lays an evidence-based data foundation for the analysis and application of inpatient rehabilitation medical record summary sheet.
