1.Structure, content and data standardization of rehabilitation medical records
Yaru YANG ; Zhuoying QIU ; Di CHEN ; Zhongyan WANG ; Meng ZHANG ; Shiyong WU ; Yaoguang ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Jian YANG ; Na AN ; Yuanjun DONG ; Xiaojia XIN ; Xiangxia REN ; Ye LIU ; Yifan TIAN
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):21-32
ObjectiveTo elucidate the critical role of rehabilitation medical records (including electronic records) in rehabilitation medicine's clinical practice and management, comprehensively analyzed the structure, core content and data standards of rehabilitation medical records, to develop a standardized medical record data architecture and core dataset suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evaluation and payment. MethodsBased on the regulatory documents Basic Specifications for Medical Record Writing and Basic Specifications for Electronic Medical Records (Trial) issued by National Health Commission of China, and referencing the World Health Organization (WHO) Family of International Classifications (WHO-FICs) classifications, International Classification of Diseases (ICD-10/ICD-11), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), this study constructed the data architecture, core content and data standards for rehabilitation medical records. Furthermore, it explored the application of rehabilitation record summary sheets (home page) data in rehabilitation medical statistics and payment methods, including Diagnosis-related Groups (DRG), Diagnosis-Intervention Packet (DIP) and Case Mix Index. ResultsThis study proposed a systematic standard framework for rehabilitation medical records, covering key components such as patient demographics, rehabilitation diagnosis, functional assessment, rehabilitation treatment prescriptions, progress evaluations and discharge summaries. The research analyzed the systematic application methods and data standards of ICD-10/ICD-11, ICF and ICHI Beta-3 in the fields of medical record terminology, coding and assessment. Constructing a standardized data structure and data standards for rehabilitation medical records can significantly improve the quality of data reporting based on the medical record summary sheet, thereby enhancing the quality control of rehabilitation services, effectively supporting the optimization of rehabilitation medical insurance payment mechanisms, and contributing to the establishment of rehabilitation medical performance evaluation and payment based on DRG and DIP. ConclusionStructured rehabilitation records and data standardization are crucial tools for quality control in rehabilitation. Systematically applying the three reference classifications of the WHO-FICs, and aligning with national medical record and electronic health record specifications, facilitate the development of a standardized rehabilitation record architecture and core dataset. Standardizing rehabilitation care pathways based on the ICF methodology, and developing ICF- and ICD-11-based rehabilitation assessment tools, auxiliary diagnostic and therapeutic systems, and supporting terminology and coding systems, can effectively enhance the quality of rehabilitation records and enable interoperability and sharing of rehabilitation data with other medical data, ultimately improving the quality and safety of rehabilitation services.
2.Standardization of electronic medical records data in rehabilitation
Yifan TIAN ; Fang XUN ; Haiyan YE ; Ye LIU ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):33-44
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.
3.Standardization of outpatient medical record in rehabilitation setting
Ye LIU ; Qing QIN ; Haiyan YE ; Yifan TIAN ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):45-54
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.
4.Structure, content and data standardization of inpatient rehabilitation medical record summary sheet
Haiyan YE ; Qing QIN ; Ye LIU ; Yifan TIAN ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):55-66
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.
5.Interpretation of critical update: AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma
Yuze ZHAO ; Yuxiao CHEN ; Kechun WANG ; Mingda WANG ; Tian YANG
Journal of Clinical Hepatology 2025;41(5):851-854
In February 2025, the American Association for the Study of Liver Diseases (AASLD) published online “Critical Update: AASLD Practice Guidance on Prevention, Diagnosis, and Treatment of Hepatocellular Carcinoma”. This update mainly focuses on the latest analysis results of the IMbrave050 study and performs corresponding updates and adjustments to recommendations based on the issues in clinical practice. As for the postoperative adjuvant therapeutic strategies for hepatocellular carcinoma (HCC) based on immune checkpoint inhibitors, the AASLD has re-evaluated and updated the practice guidance. The update revises related texts and recommendations for adjuvant therapy and the management algorithms for HCC recurrence during or after adjuvant therapy. Furthermore, the AASLD emphasizes that even for HCC patients at a high risk of recurrence after resection or local ablation, close monitoring for recurrence remains the current standard treatment regimen. Our team makes an excerpt of the update, systematically introduces the background and specific contents of the update, and discuss the adjuvant therapy for HCC, in order to provide a reference for readers.
6.A DPAL method for the identification of the synergistic target of drugs.
Dongyao WANG ; Yuxiao TANG ; Na LI ; Chenghua WU ; Jianxin YANG ; Mengpu WU ; Feng LU ; Yifeng CHAI ; Chenqi LI ; Hui SHEN ; Xin DONG ; Changquan LING
Journal of Pharmaceutical Analysis 2025;15(11):101351-101351
Image 1.
7.Effects of Taoren Honghua decoction combined with rehabilitation training on neurological function and serum MDA,bFGF,PTX3 levels in patients with cerebral ischemia-reperfusion injury
Pei YANG ; Yuxiao ZHU ; Nan LI
International Journal of Laboratory Medicine 2024;45(16):2005-2009
Objective To investigate the Effects of Taoren Honghua decoction combined with rehabilitation training on neurological function and serum malondialdehyde(MDA),basic fibroblast growth factor(bFGF)and pentraxin 3(PTX3)levels in patients with cerebral ischemia-reperfusion injury(CIRI).Methods A total of 100 CIRI patients treated in Dingzhou People's Hospital from June 2020 to May 2023 as the study objects were randomly divided into treatment group(50 cases)and control group(50 cases).The control group was given routine treatment combined with rehabilitation training,and the treatment group was given Taoren Honghua decoction on the basis of the control group.The treatment effect,the score of National Institutes of Health Stroke Scale(NIHSS)and the score of Daily Living Ability Scale(ADL)before and after treatment were compared between the two groups,and the adverse reactions were recorded.Results The total effective rate of the treatment group[86.00%(43/50)]was significantly higher than that of the control group[68.00%(34/50)],and the difference was statistically significant(P<0.05).Compared with before treat-ment,the NIHSS score of the treatment group and the control group was significantly decreased after treat-ment,and the ADL score was significantly increased,with statistical significance(P<0.05).After treatment,compared with the control group,the NIHSS score in the treatment group was significantly decreased,and the ADL score was significantly increased,with statistical significance(P<0.05).After treatment,compared with the control group,the levels of MDA and PTX3 in the treatment group were significantly decreased,while the levels of superoxide dismutase,bFGF,insulin-like growth factor 1 and vascular endothelial growth factor were significantly increased in the treatment group,with statistical significance(P<0.05).The incidence of ad-verse reactions in the treatment group[12.00%(6/50)]was significantly lower than that in the control group[30.00%(15/50)],and the difference was statistically significant(P<0.05).Conclusion Taoren Honghua Decoction combined with rehabilitation training has a good therapeutic effect on CIRI patients,and can im-prove the neurological function of patients.
8.Research progress on irradiation sterilization of traditional Chinese medicine
Chen YANG ; Yuxiao ZHENG ; Xinyuan XU ; Yuehui LI
China Pharmacist 2024;28(10):331-340
Sterilization is one of the key links in the production of traditional Chinese medicine,and it is also an important factor to ensure the safety,effectiveness and quality control of traditional Chinese medicine.Traditional sterilization techniques such as moist heat sterilization are limited in many cases due to their inherent shortcomings.In contrast,irradiation sterilization has attracted more and more attention due to its advantages of fast,efficient,strong sterilization and low cost.However,the chemical composition of traditional Chinese medicine is complex,due to the radioactivity and strong penetration of irradiation,after a certain dose of irradiation,its chemical composition and pharmacological activity may change.At present,there is still a lack of systematic research on the changes of chemical composition,effectiveness and safety of traditional Chinese medicine after irradiation sterilization.Based on the research status of 60Co-γ ray and electron beam irradiation sterilization in the sterilization of traditional Chinese medicine in recent years,this paper reviews the effects of irradiation on the effectiveness of traditional Chinese medicine,the detection methods of irradiation and the safety evaluation,in order to provide some reference for the subsequent application of irradiation sterilization of traditional Chinese medicine.
9.Reliability and validity of assessment tools of Brief ICF Core Sets for Arthroplasty of Knee Osteoarthritis in Peri-operative Period
Boyang YU ; Yanyan YANG ; Ao MA ; Tao LI ; Xiaoxie LIU ; Zhengyang LI ; Yajing DUAN ; Jiaqi LIU ; Yuxiao XIE ; Cui WANG ; Zhen HUANG ; Lining ZHANG ; Xinyi LIU ; Zishan JIA ; Mouwang ZHOU
Chinese Journal of Rehabilitation Theory and Practice 2024;30(9):1053-1059
Objective To investigate the reliability and validity of the assessment tools of Brief ICF Core Sets for Arthroplasty of Knee Osteoarthritis in Perioperative Period(ICSAKOPP). Methods From May,2022 to April,2023,320 patients undergoing knee arthroplasty were selected in Peking University Third Hospital,China-Japan Friendship Hospital,Peking University First Hospital and Chinese PLA General Hospital.Trained assessors used Brief ICSAKOPP to evaluate all enrolled patients before arthroplasty,three days(±one day)after arthroplasty,three weeks(±one week)after arthroplasty,and three months(±one month)after ar-throplasty.Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)scores were recorded at the same time.Five professionals were asked to score all the items of Brief ICSAKOPP,and the content validity index(CVI)was caculated. Results A total of 64 cases were dropped down.CVI of all the items of the Brief ICSAKOPP were above 0.8,with a av-erage CVI of the scale of 0.938.The Cronbach's α coefficient of the Brief ICSAKOPP was 0.813.There was a moderate correlation(r=0.681,P<0.001)between the overall Brief ICSAKOPP and WOMAC scores,as well as body functional dimension score(r=0.668,P<0.001)and activities and participation dimension score(r=0.657,P<0.001). Conclusion Brief ICSAKOPP is good in content validity,internal consistency reliability and criterion validity.
10.Treatment of Endometriosis from the Perspective of "Retention due to Deficiency Qi"
Yujuan ZHANG ; Youhua ZHU ; Jiajing ZHAO ; Yanan YANG ; Mengya BU ; Mengxin FANG ; Yuxiao HUANG
Journal of Traditional Chinese Medicine 2024;65(9):954-957
It is believed that retention due to deficient qi is an important pathogenesis of endometriosis (EMs). Deficient qi is the root of the disease, mainly manifested as spleen deficiency, while retention is the branch pathogenesis of the disease, mainly with blood stasis, complicated with constraint, phlegm, heat, toxin and other pathological factors. Therefore, it is proposed to follow the treatment principle of supplementing deficiency and unblocking stagnation, and take the methods of replenishing qi and fortifying the spleen, removing stasis and eliminating concretions. Self-made Fuzheng Huayu Formula (扶正化瘀方) is taken as the basic formula, and can be modified with the symptoms in menstrual and non-menstrual periods. Additionally, the methods of moving qi, dispelling phlegm, clearing heat, relieving toxin and others can be combined, and it is recommended to treat the root and the branch simultaneously.

Result Analysis
Print
Save
E-mail