1.Mechanisms of Shenqi Wenfei Prescription in Intervening in Chronic Obstructive Pulmonary Disease in Rats Based on ROS/TXNIP/NLRP3 Signaling Pathway
Di WU ; Mengyao SHI ; Lu ZHANG ; Tong LIU ; Jiabing TONG ; Cheng YANG ; Zegeng LI
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(3):78-87
ObjectiveTo investigate the effects and underlying mechanisms of Shenqi Wenfei prescription (SQWF) on chronic obstructive pulmonary disease (COPD). MethodsA rat model of COPD with lung Qi deficiency was established using lipopolysaccharide (LPS) combined with cigarette smoke. Forty-eight SD rats were randomly divided into a blank group, a model group, low-, medium-, and high-dose SQWF groups (2.835, 5.67, 11.34 g·kg-1), and a Yupingfeng group (1.35 g·kg-1). Drug administration began on day 29 after modeling and continued for 2 weeks. The general condition of the rats was observed, and the lung function in each group was assessed. Hematoxylin-eosin (HE) staining was used to observe pathological changes in lung tissue. The proportion of inflammatory cells in bronchoalveolar lavage fluid (BALF) was measured. Apoptosis in lung tissue was examined by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining. The release level of lactate dehydrogenase (LDH) in BALF was detected by a microplate assay. Reactive oxygen species (ROS) levels in lung tissue were detected using fluorescent probes. The levels of malondialdehyde (MDA), total superoxide dismutase (SOD), and reduced glutathione (GSH) in BALF were measured by biochemical methods. Ultrastructural changes in lung cells were observed via transmission electron microscopy. Double immunofluorescence staining was performed to detect the expression of thioredoxin-interacting protein (TXNIP) and nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) in lung tissue. Western blot analysis was used to detect the protein expression of TXNIP, NLRP3, apoptosis-associated speck-like protein containing a CARD (ASC), cysteinyl aspartate-specific protease-1 (Caspase-1), Caspase-1 p20, gasdermin D (GSDMD), GSDMD N-terminal active fragment (GSDMD-N), interleukin-1β (IL-1β), and IL-18 in lung tissue. Serum IL-1β and IL-18 levels were measured by ELISA. ResultsCompared with the blank group, the model group showed lassitude, fatigue, tachypnea, and audible phlegm sounds, and lung function significantly declined (P0.01). Pulmonary emphysema and inflammatory cell infiltration were obvious. The level of inflammatory cells in BALF increased significantly (P0.05). The number of TUNEL-positive cells increased (P0.01). Levels of LDH, ROS, and MDA in BALF increased significantly (P0.01), while GSH and SOD activities decreased significantly (P0.01). Lung tissue cells showed irregular morphology, swollen mitochondria, disrupted cell membranes, and abundant vesicles, i.e., pyroptotic bodies. Protein levels of TXNIP, NLRP3, ASC, Caspase-1, Caspase-1 p20, GSDMD, GSDMD-N, IL-1β, and IL-18 in lung tissue were significantly elevated (P0.01), and serum IL-1β and IL-18 levels also increased significantly (P0.01). Compared with the model group, each medication group showed alleviation of qi deficiency symptoms and improved lung function (P0.01). Pulmonary emphysema and inflammatory cell infiltration were reduced. Inflammatory cell levels decreased (P0.05). The number of TUNEL-positive cells decreased significantly (P0.01). Levels of LDH, ROS, and MDA decreased significantly (P0.05), while GSH and SOD activities significantly increased (P0.01). Morphological and structural damage in lung tissue was improved to varying degrees. Protein levels of TXNIP, NLRP3, ASC, Caspase-1, Caspase-1 p20, GSDMD, GSDMD-N, IL-1β, and IL-18 in lung tissue significantly decreased (P0.01), and serum IL-1β and IL-18 levels also decreased significantly (P0.05). ConclusionSQWF can improve lung function and alleviate inflammatory responses in COPD rats. Its mechanism may be related to regulating the ROS/TXNIP/NLRP3 pathway and inhibiting pyroptosis.
2.Herbal Textual Research on Inulae Flos in Famous Classical Formulas
Caixia LIU ; Yue HAN ; Yanzhu MA ; Lei GAO ; Sheng WANG ; Yan YANG ; Wenchuan LUO ; Ling JIN ; Jing SHAO ; Zhijia CUI ; Zhilai ZHAN
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(3):210-221
In this paper, by referring to ancient and modern literature, the textual research of Inulae Flos has been conducted to clarify the name, origin, production area, quality evaluation, harvesting, processing and others, so as to provide reference and basis for the development and utilization of famous classical formulas containing this herb. After textual research, it could be verified that the medicinal use of Inulae Flos was first recorded in Shennong Bencaojing of the Han dynasty. In successive dynasties, Xuanfuhua has been taken as the official name, and it also has other alternative names such as Jinfeicao, Daogeng and Jinqianhua. The period before the Song and Yuan dynasties, the main origin of Inulae Flos was the Asteraceae plant Inula japonica, and from the Ming and Qing dynasties to the present, I. japonica and I. britannica are the primary source. In addition to the dominant basal species, there are also regional species such as I. linariifolia, I. helianthus-aquatili, and I. hupehensis. The earliest recorded production areas in ancient times were Henan, Hubei and other places, and the literature records that it has been distributed throughout the country since modern times. The medicinal part is its flower, the harvesting and processing method recorded in the past dynasties is mainly harvested in the fifth and ninth lunar months, and dried in the sun, and the modern harvesting is mostly harvested in summer and autumn when the flowers bloom, in order to remove impurities, dry in the shade or dry in the sun. In addition, the roots, whole herbs and aerial parts are used as medicinal materials. In ancient times, there were no records about the quality of Inulae Flos, and in modern times, it is generally believed that the quality of complete flower structure, small receptacles, large blooms, yellow petals, long filaments, many fluffs, no fragments, and no branches is better. Ancient processing methods primarily involved cleaning, steaming, and sun-drying, supplemented by techniques such as boiling, roasting, burning, simmering, stir-frying, and honey-processing. Modern processing focuses mainly on cleaning the stems and leaves before use. Regarding the medicinal properties, ancient texts describe it as salty and sweet in taste, slightly warm in nature, and mildly toxic. Modern studies characterize it as bitter, pungent, and salty in taste, with a slightly warm nature. Its therapeutic effects remain consistent across eras, including descending Qi, resolving phlegm, promoting diuresis, and stopping vomiting. Based on the research results, it is recommended that when developing famous classical formulas containing Inulae Flos, either I. japonica or I. britannica should be used as the medicinal source. Processing methods should follow formula requirements, where no processing instructions are specified, the raw products may be used after cleaning.
3.Mechanisms of Shenqi Wenfei Prescription in Intervening in Chronic Obstructive Pulmonary Disease in Rats Based on ROS/TXNIP/NLRP3 Signaling Pathway
Di WU ; Mengyao SHI ; Lu ZHANG ; Tong LIU ; Jiabing TONG ; Cheng YANG ; Zegeng LI
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(3):78-87
ObjectiveTo investigate the effects and underlying mechanisms of Shenqi Wenfei prescription (SQWF) on chronic obstructive pulmonary disease (COPD). MethodsA rat model of COPD with lung Qi deficiency was established using lipopolysaccharide (LPS) combined with cigarette smoke. Forty-eight SD rats were randomly divided into a blank group, a model group, low-, medium-, and high-dose SQWF groups (2.835, 5.67, 11.34 g·kg-1), and a Yupingfeng group (1.35 g·kg-1). Drug administration began on day 29 after modeling and continued for 2 weeks. The general condition of the rats was observed, and the lung function in each group was assessed. Hematoxylin-eosin (HE) staining was used to observe pathological changes in lung tissue. The proportion of inflammatory cells in bronchoalveolar lavage fluid (BALF) was measured. Apoptosis in lung tissue was examined by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining. The release level of lactate dehydrogenase (LDH) in BALF was detected by a microplate assay. Reactive oxygen species (ROS) levels in lung tissue were detected using fluorescent probes. The levels of malondialdehyde (MDA), total superoxide dismutase (SOD), and reduced glutathione (GSH) in BALF were measured by biochemical methods. Ultrastructural changes in lung cells were observed via transmission electron microscopy. Double immunofluorescence staining was performed to detect the expression of thioredoxin-interacting protein (TXNIP) and nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) in lung tissue. Western blot analysis was used to detect the protein expression of TXNIP, NLRP3, apoptosis-associated speck-like protein containing a CARD (ASC), cysteinyl aspartate-specific protease-1 (Caspase-1), Caspase-1 p20, gasdermin D (GSDMD), GSDMD N-terminal active fragment (GSDMD-N), interleukin-1β (IL-1β), and IL-18 in lung tissue. Serum IL-1β and IL-18 levels were measured by ELISA. ResultsCompared with the blank group, the model group showed lassitude, fatigue, tachypnea, and audible phlegm sounds, and lung function significantly declined (P0.01). Pulmonary emphysema and inflammatory cell infiltration were obvious. The level of inflammatory cells in BALF increased significantly (P0.05). The number of TUNEL-positive cells increased (P0.01). Levels of LDH, ROS, and MDA in BALF increased significantly (P0.01), while GSH and SOD activities decreased significantly (P0.01). Lung tissue cells showed irregular morphology, swollen mitochondria, disrupted cell membranes, and abundant vesicles, i.e., pyroptotic bodies. Protein levels of TXNIP, NLRP3, ASC, Caspase-1, Caspase-1 p20, GSDMD, GSDMD-N, IL-1β, and IL-18 in lung tissue were significantly elevated (P0.01), and serum IL-1β and IL-18 levels also increased significantly (P0.01). Compared with the model group, each medication group showed alleviation of qi deficiency symptoms and improved lung function (P0.01). Pulmonary emphysema and inflammatory cell infiltration were reduced. Inflammatory cell levels decreased (P0.05). The number of TUNEL-positive cells decreased significantly (P0.01). Levels of LDH, ROS, and MDA decreased significantly (P0.05), while GSH and SOD activities significantly increased (P0.01). Morphological and structural damage in lung tissue was improved to varying degrees. Protein levels of TXNIP, NLRP3, ASC, Caspase-1, Caspase-1 p20, GSDMD, GSDMD-N, IL-1β, and IL-18 in lung tissue significantly decreased (P0.01), and serum IL-1β and IL-18 levels also decreased significantly (P0.05). ConclusionSQWF can improve lung function and alleviate inflammatory responses in COPD rats. Its mechanism may be related to regulating the ROS/TXNIP/NLRP3 pathway and inhibiting pyroptosis.
4.Herbal Textual Research on Inulae Flos in Famous Classical Formulas
Caixia LIU ; Yue HAN ; Yanzhu MA ; Lei GAO ; Sheng WANG ; Yan YANG ; Wenchuan LUO ; Ling JIN ; Jing SHAO ; Zhijia CUI ; Zhilai ZHAN
Chinese Journal of Experimental Traditional Medical Formulae 2026;32(3):210-221
In this paper, by referring to ancient and modern literature, the textual research of Inulae Flos has been conducted to clarify the name, origin, production area, quality evaluation, harvesting, processing and others, so as to provide reference and basis for the development and utilization of famous classical formulas containing this herb. After textual research, it could be verified that the medicinal use of Inulae Flos was first recorded in Shennong Bencaojing of the Han dynasty. In successive dynasties, Xuanfuhua has been taken as the official name, and it also has other alternative names such as Jinfeicao, Daogeng and Jinqianhua. The period before the Song and Yuan dynasties, the main origin of Inulae Flos was the Asteraceae plant Inula japonica, and from the Ming and Qing dynasties to the present, I. japonica and I. britannica are the primary source. In addition to the dominant basal species, there are also regional species such as I. linariifolia, I. helianthus-aquatili, and I. hupehensis. The earliest recorded production areas in ancient times were Henan, Hubei and other places, and the literature records that it has been distributed throughout the country since modern times. The medicinal part is its flower, the harvesting and processing method recorded in the past dynasties is mainly harvested in the fifth and ninth lunar months, and dried in the sun, and the modern harvesting is mostly harvested in summer and autumn when the flowers bloom, in order to remove impurities, dry in the shade or dry in the sun. In addition, the roots, whole herbs and aerial parts are used as medicinal materials. In ancient times, there were no records about the quality of Inulae Flos, and in modern times, it is generally believed that the quality of complete flower structure, small receptacles, large blooms, yellow petals, long filaments, many fluffs, no fragments, and no branches is better. Ancient processing methods primarily involved cleaning, steaming, and sun-drying, supplemented by techniques such as boiling, roasting, burning, simmering, stir-frying, and honey-processing. Modern processing focuses mainly on cleaning the stems and leaves before use. Regarding the medicinal properties, ancient texts describe it as salty and sweet in taste, slightly warm in nature, and mildly toxic. Modern studies characterize it as bitter, pungent, and salty in taste, with a slightly warm nature. Its therapeutic effects remain consistent across eras, including descending Qi, resolving phlegm, promoting diuresis, and stopping vomiting. Based on the research results, it is recommended that when developing famous classical formulas containing Inulae Flos, either I. japonica or I. britannica should be used as the medicinal source. Processing methods should follow formula requirements, where no processing instructions are specified, the raw products may be used after cleaning.
5.Herbal Textual Research on Dioscoreae Hypoglaucae Rhizoma, Dioscoreae Spongiosae Rhizoma, Smilacis Chinae Rhizoma and Smilacis Glabrae Rhizoma in Famous Classical Formulas
Li LU ; Yichen YANG ; Erhuan WANG ; Hui CHANG ; Li AN ; Shibao WANG ; Cunde MA ; Zhilai ZHAN
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(5):218-247
This article systematically reviews and verifies the medicinal materials of Dioscoreae Hypoglaucae Rhizoma(DHR), Dioscoreae Spongiosae Rhizoma(DSR), Smilacis Chinae Rhizoma(SCR) and Smilacis Glabrae Rhizoma(SGR) from the aspects of name, origin, producing area, quality, harvesting, processing and efficacy by consulting historical literature, in order to provide reference for the development and utilization of famous classical formulas containing the four medicinal materials. DHR, DSR, SCR and SGR have a long history of application as medicinal materials. However, due to their similar growth environment and medicinal properties, as well as their functions of promoting dampness, dispelling wind and removing numbness, there have been instances of homonymous foreign objects and homonymous synonyms throughout history, resulting in confusion of the origin. Therefore, it is necessary to conduct comparative analysis and systematic research for clarifying the historical development and changes of the four, in order to provide a basis for safe and effective medication. According to research, Bixie was first recorded in Shennong Bencaojing and has been historically known as Baizhi, Chijie, Zhumu, and other aliases. From ancient times to the mid-20th century, there has always been a situation where the rhizomes of Dioscorea plants and Smilax plants, and even the rhizomes of Heterosmilax plants, were mixed together to be used as medicinal herbs for Bixie. However, since the Tang dynasty, it has been clearly advocated that the rhizomes of Dioscorea plants have excellent quality and have been the mainstream throughout history. The 2020 edition of Chinese Pharmacopoeia categorized it into two types of medicinal herbs(DHR and DSR). Among them, the origin of DHR is the dry rhizomes of Dioscorea hypoglauca, and the origins of DSR are the dry rhizomes of D. spongiosa and D. futschauensis. In ancient times, due to different types, the corresponding production areas of DHR and DSR were also different. Nowadays, They are mainly produced in the southern region of the Yangtze River. Since the Tang dynasty, the quality of Bixie has been characterized by its white color and soft nature. In modern times, it has been summarized that those with white color, large and thin pieces, powdery texture, tough and elastic texture, and neat and unbreakable are the best. The harvesting times of DHR and DSR are in spring or autumn, with the best quality harvested in autumn. The mainstream processing methods of them are slicing and then using the raw products or wine-processed products. SCR was first recorded in Mingyi Bielu and has been known as Jinganggen, Tielingjiao, Tieshuazi, and other aliases in history. The mainstream source is the dry rhizomes of Smilax china in the past dynasties, with the best quality being those that are tough and rich in powder. The harvesting time is from the late autumn to the following spring, and the main processing method throughout history has been slicing for raw use. SGR was first recorded under the item of Yuyuliang in Variorum of Shennong's Classic of Materia Medica. It was listed as an independent medicinal material from Bencao Gangmu. In history, there were such aliases as Cao Yuyuliang, Lengfantuan, Xianyiliang, Tubixie, etc. The main source of the past dynasties was dry rhizomes of S. glabra. In history, there have also been instances of multiple plants belonging to the same genus, and even cases of mixing the rhizomes of plants in the genus Heterosmilax. It is mainly produced in Guangdong, Hunan, Hubei, Zhejiang, Sichuan, Anhui and other regions, its quality has been summarized as large in size, powdery in texture, with few veins, and light brown in cross-section since modern times. The harvesting time is in spring or autumn, and the main processing method throughout history has been slicing for raw use. DHR, DSR, SCR and SGR all have the effects of promoting dampness, dispelling wind, relieving rheumatism and detoxifying. However, their detoxification abilities are ranked as follows:SGR>SCR>Bixie(DHR and DSR). Especially for the treatment of limb spasms, arthralgia and myalgia, scrofula, and scabies caused by syphilis and mercury poisoning, SGR has a unique effect. Based on the research results, DHR is recommended to develop the famous classical formulas containing Bixie as the first choice for medicinal herbs. It should be harvested in autumn, sliced thinly while fresh, and processed according to the requirements of the famous classical formulas, without any requirements for raw use. Selecting the rhizomes of S. china, harvested in late autumn, and thinly sliced while fresh. If there are no special processing requirements in the formulas, use it raw. Selecting the rhizomes of S. glabra, it is harvested in autumn and thinly sliced while fresh. If there are no special processing requirements in the formulas, raw products can be used.
6.Molecular biological research and molecular homologous modeling of Bw.03 subgroup
Li WANG ; Yongkui KONG ; Huifang JIN ; Xin LIU ; Ying XIE ; Xue LIU ; Yanli CHANG ; Yafang WANG ; Shumiao YANG ; Di ZHU ; Qiankun YANG
Chinese Journal of Blood Transfusion 2025;38(1):112-115
[Objective] To study the molecular biological mechanism for a case of ABO blood group B subtype, and perform three-dimensional modeling of the mutant enzyme. [Methods] The ABO phenotype was identified by the tube method and microcolumn gel method; the ABO gene of the proband was detected by sequence-specific primer polymerase chain reaction (PCR-SSP), and the exon 6 and 7 of the ABO gene were sequenced and analyzed. Homologous modeling of Bw.03 glycosyltransferase (GT) was carried out by Modeller and analyzed by PyMOL2.5.0 software. [Results] The weakening B antigen was detected in the proband sample by forward typing, and anti-B antibody was detected by reverse typing. PCR-SSP detection showed B, O gene, and the sequencing results showed c.721 C>T mutation in exon 7 of the B gene, resulting in p. Arg 241 Trp. Compared with the wild type, the structure of Bw.03GT was partially changed, and the intermolecular force analysis showed that the original three hydrogen bonds at 241 position disappeared. [Conclusion] Blood group molecular biology examination is helpful for the accurate identification of ambiguous blood group. Homologous modeling more intuitively shows the key site for the weakening of Bw.03 GT activity. The intermolecular force analysis can explain the root cause of enzyme activity weakening.
7.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.
8.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.
9.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.
10.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.

Result Analysis
Print
Save
E-mail