1.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.
2.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.
3.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.
4.Analysis on the effect of AI rehabilitation system combined with telemedicine platform in individualized rehabilitation treatment for patients with long-term coma
Weixiang QIU ; Banggui CHEN ; Wanqin WANG ; Shuxiong CAI ; Chao XU ; Ligen HUANG ; Bo ZHANG ; Bing MENG
China Medical Equipment 2025;22(11):137-142
Objective:To analyze the applied effect of artificial intelligence(AI)rehabilitation system combined with telemedicine platform in individualized rehabilitation treatment for patients with long-term coma,so as to realize individual management for them.Methods:An AI rehabilitation system that aimed to patients with long-term coma was designed by integrating data of multimodal sensors included inertial sensor,image sensor and bioelectric sensor.A telemedicine platform,which included seven modules(patient management,consultation management,video communication,data transmission,electronic medical records,cost management and system maintenance),was designed by using a browser/server(B/S)architecture.The changes of patients'condition were followed up,and the full process of the management for rehabilitation treatment and the individualization of treatment plan were realized.A total of 60 inpatients whose coma duration exceeded 28 days were selected from the Coma Awakening Center of Dongguan Shipai Hospital between October 1,2021 and September 30,2022.They were randomly divided into control group(n=30)and observation group(n=30)by random number table.The control group received physical therapy and rehabilitation training based on evaluation results of rehabilitation,while the observation group adopted AI rehabilitation system combined with the telemedicine platform to conduct intervention.The consciousness levels,quality of life,hospital stay duration and treatment costs of two group were compared after intervention.Results:The Glasgow Coma Scale(GCS)scores,Coma Recovery Scale-Revised(CRS-R)scores,and Persistent Vegetative State(PVS)scores of two groups after intervention were significantly higher than those before intervention,and these indicators of observation group were significantly higher than them of control group after intervention,and the differences were significant(t=7.187,15.586,9.293,P<0.05),respectively.There were not significant differences in Glasgow Outcome Scale(GOS)scores and Activities of Daily Living(ADL)scores between two groups before intervention(P>0.05),and these scores of two groups were significantly increased after intervention,and these scores of observation group were significantly higher than them of control group after intervention,and the differences were significant(t=7.584,6.755,P<0.05).Additionally,the hospital stay duration and treatment costs of observation group were significantly less than those of control group,and the differences were significant(t=20.965,9.503,P<0.05).Conclusion:The intervention of AI rehabilitation system combines with a telemedicine platform on patients with long-term coma can enhance GCS,CRS-R,PVS,GOS and ADL scores,and reduce hospital stay duration and treatment cost.
5.Research on brain damage and therapeutic effects of comorbid auditory and visual hallucinations and cognitive decline in patients with first-episode schizophrenia based on brain magnetic resonance imaging
Chunhai HUANG ; Wenzhen TU ; Ce CHEN ; Lei MENG ; Lixue QIU ; Jianjing ZHANG
Chinese Journal of Primary Medicine and Pharmacy 2025;32(9):1331-1336
Objective:To investigate brain damage and treatment efficacy in patients with first-episode schizophrenia with comorbid auditory and visual hallucinations and cognitive decline based on brain magnetic resonance imaging (MRI).Methods:This study adopted a retrospective cohort design. Eighty patients with first-episode schizophrenia who received treatment at Wenzhou Seventh People's Hospital from January to June 2024 were included in this study. The patients were divided into an observation group (40 cases of first-episode schizophrenia with comorbid auditory and visual hallucinations) and a control group (40 cases of first-episode schizophrenia without comorbid auditory and visual hallucinations) based on whether they had symptoms of comorbid auditory and visual hallucinations. Forty healthy individuals who concurrently underwent physical examinations were included in the normal group. All patients received standardized treatment. Cranial MRI data were collected from all subjects. Cranial MRI data, Positive and Negative Syndrome Scale (PANSS) score, Global Assessment of Functioning (GAF) score, and changes in cognitive function were compared among the three groups. Additionally, the changes in cranial MRI data, PANSS score, GAF score, and the score of MATRICS Consensus Cognitive Battery (MCCB) in the observation group were compared between before and after treatment.Results:The horizontal distance between the corpus callosum and the underside of the cingulate gyrus, the vertical distance between the corpus callosum and the underside of the cingulate gyrus, and PANSS and GAF scores in the observation group were all significantly higher than those in the normal and control groups (all P < 0.05). The scores on all MCCB scales in the observation group were significantly lower than those in the normal and control groups (all P < 0.05). After treatment, the left horizontal distance between the corpus callosum and the underside of the cingulate gyrus [(5.72 ± 0.71) mm] and the right horizontal distance [(5.13 ± 0.55) mm], as well as the left vertical distance [(6.37 ± 0.69) mm] and the right vertical distance [(5.61 ± 0.67) mm], were all significantly lower than the pre-treatment values [(6.98 ± 0.83) mm, (6.07 ± 0.49) mm, (7.54 ± 0.58) mm, and (6.52 ± 0.51) mm, t = 7.30, 8.07, 8.21, 6.84, all P < 0.05]. Post-treatment PANSS scores [(39.95 ± 6.65)] were significantly lower than pre-treatment scores [(97.47 ± 18.47)], while post-treatment GAF scores [(71.26 ± 8.87)] were significantly higher than pre-treatment scores [(34.68 ± 7.71), t = 18.53, 19.69, both P < 0.05]. Post-treatment scores for the MCCB [(8.57 ± 2.45), (2.25 ± 0.47), (25.16 ± 2.43), (24.10 ± 2.64), (17.08 ± 2.25), (20.43 ± 3.76), (2.07 ± 0.36), (22.16 ± 3.24), (57.81 ± 7.69), (0.28 ± 0.05)] were significantly higher than pre-treatment scores [(5.65 ± 1.37), (1.62 ± 0.34), (21.21 ± 2.27), (20.27 ± 1.78), (12.16 ± 2.08), (14.56 ± 2.34), (1.71 ± 0.25), (17.92 ± 1.64), (40.29 ± 6.56), (0.21 ± 0.03), t = 6.58, 6.87, 7.51, 7.61, 10.15, 8.38, 5.19, 7.38, 10.96, 7.59, all P < 0.05]. Conclusions:The comorbid auditory and visual hallucinations in patients with first-episode schizophrenia, based on brain MRI findings, are closely related to cognitive decline and brain damage. After treatment, both cognitive function and cranial damage in these patients have considerably improved, which is worthy of clinical consideration.
6.Expert consensus on the application of nasal cavity filling substances in nasal surgery patients(2025, Shanghai).
Keqing ZHAO ; Shaoqing YU ; Hongquan WEI ; Chenjie YU ; Guangke WANG ; Shijie QIU ; Yanjun WANG ; Hongtao ZHEN ; Yucheng YANG ; Yurong GU ; Tao GUO ; Feng LIU ; Meiping LU ; Bin SUN ; Yanli YANG ; Yuzhu WAN ; Cuida MENG ; Yanan SUN ; Yi ZHAO ; Qun LI ; An LI ; Luo BA ; Linli TIAN ; Guodong YU ; Xin FENG ; Wen LIU ; Yongtuan LI ; Jian WU ; De HUAI ; Dongsheng GU ; Hanqiang LU ; Xinyi SHI ; Huiping YE ; Yan JIANG ; Weitian ZHANG ; Yu XU ; Zhenxiao HUANG ; Huabin LI
Journal of Clinical Otorhinolaryngology Head and Neck Surgery 2025;39(4):285-291
This consensus will introduce the characteristics of fillers used in the surgical cavities of domestic nasal surgery patients based on relevant literature and expert opinions. It will also provide recommendations for the selection of cavity fillers for different nasal diseases, with chronic sinusitis as a representative example.
Humans
;
Nasal Cavity/surgery*
;
Nasal Surgical Procedures
;
China
;
Consensus
;
Sinusitis/surgery*
;
Dermal Fillers
7.Expert consensus on apical microsurgery.
Hanguo WANG ; Xin XU ; Zhuan BIAN ; Jingping LIANG ; Zhi CHEN ; Benxiang HOU ; Lihong QIU ; Wenxia CHEN ; Xi WEI ; Kaijin HU ; Qintao WANG ; Zuhua WANG ; Jiyao LI ; Dingming HUANG ; Xiaoyan WANG ; Zhengwei HUANG ; Liuyan MENG ; Chen ZHANG ; Fangfang XIE ; Di YANG ; Jinhua YU ; Jin ZHAO ; Yihuai PAN ; Shuang PAN ; Deqin YANG ; Weidong NIU ; Qi ZHANG ; Shuli DENG ; Jingzhi MA ; Xiuping MENG ; Jian YANG ; Jiayuan WU ; Yi DU ; Junqi LING ; Lin YUE ; Xuedong ZHOU ; Qing YU
International Journal of Oral Science 2025;17(1):2-2
Apical microsurgery is accurate and minimally invasive, produces few complications, and has a success rate of more than 90%. However, due to the lack of awareness and understanding of apical microsurgery by dental general practitioners and even endodontists, many clinical problems remain to be overcome. The consensus has gathered well-known domestic experts to hold a series of special discussions and reached the consensus. This document specifies the indications, contraindications, preoperative preparations, operational procedures, complication prevention measures, and efficacy evaluation of apical microsurgery and is applicable to dentists who perform apical microsurgery after systematic training.
Microsurgery/standards*
;
Humans
;
Apicoectomy
;
Contraindications, Procedure
;
Tooth Apex/diagnostic imaging*
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Postoperative Complications/prevention & control*
;
Consensus
;
Treatment Outcome
8.Expert consensus on pulpotomy in the management of mature permanent teeth with pulpitis.
Lu ZHANG ; Chen LIN ; Zhuo CHEN ; Lin YUE ; Qing YU ; Benxiang HOU ; Junqi LING ; Jingping LIANG ; Xi WEI ; Wenxia CHEN ; Lihong QIU ; Jiyao LI ; Yumei NIU ; Zhengmei LIN ; Lei CHENG ; Wenxi HE ; Xiaoyan WANG ; Dingming HUANG ; Zhengwei HUANG ; Weidong NIU ; Qi ZHANG ; Chen ZHANG ; Deqin YANG ; Jinhua YU ; Jin ZHAO ; Yihuai PAN ; Jingzhi MA ; Shuli DENG ; Xiaoli XIE ; Xiuping MENG ; Jian YANG ; Xuedong ZHOU ; Zhi CHEN
International Journal of Oral Science 2025;17(1):4-4
Pulpotomy, which belongs to vital pulp therapy, has become a strategy for managing pulpitis in recent decades. This minimally invasive treatment reflects the recognition of preserving healthy dental pulp and optimizing long-term patient-centered outcomes. Pulpotomy is categorized into partial pulpotomy (PP), the removal of a partial segment of the coronal pulp tissue, and full pulpotomy (FP), the removal of whole coronal pulp, which is followed by applying the biomaterials onto the remaining pulp tissue and ultimately restoring the tooth. Procedural decisions for the amount of pulp tissue removal or retention depend on the diagnostic of pulp vitality, the overall treatment plan, the patient's general health status, and pulp inflammation reassessment during operation. This statement represents the consensus of an expert committee convened by the Society of Cariology and Endodontics, Chinese Stomatological Association. It addresses the current evidence to support the application of pulpotomy as a potential alternative to root canal treatment (RCT) on mature permanent teeth with pulpitis from a biological basis, the development of capping biomaterial, and the diagnostic considerations to evidence-based medicine. This expert statement intends to provide a clinical protocol of pulpotomy, which facilitates practitioners in choosing the optimal procedure and increasing their confidence in this rapidly evolving field.
Humans
;
Calcium Compounds/therapeutic use*
;
Consensus
;
Dental Pulp
;
Dentition, Permanent
;
Oxides/therapeutic use*
;
Pulpitis/therapy*
;
Pulpotomy/standards*
9.Expert consensus on intentional tooth replantation.
Zhengmei LIN ; Dingming HUANG ; Shuheng HUANG ; Zhi CHEN ; Qing YU ; Benxiang HOU ; Lihong QIU ; Wenxia CHEN ; Jiyao LI ; Xiaoyan WANG ; Zhengwei HUANG ; Jinhua YU ; Jin ZHAO ; Yihuai PAN ; Shuang PAN ; Deqin YANG ; Weidong NIU ; Qi ZHANG ; Shuli DENG ; Jingzhi MA ; Xiuping MENG ; Jian YANG ; Jiayuan WU ; Lan ZHANG ; Jin ZHANG ; Xiaoli XIE ; Jinpu CHU ; Kehua QUE ; Xuejun GE ; Xiaojing HUANG ; Zhe MA ; Lin YUE ; Xuedong ZHOU ; Junqi LING
International Journal of Oral Science 2025;17(1):16-16
Intentional tooth replantation (ITR) is an advanced treatment modality and the procedure of last resort for preserving teeth with inaccessible endodontic or resorptive lesions. ITR is defined as the deliberate extraction of a tooth; evaluation of the root surface, endodontic manipulation, and repair; and placement of the tooth back into its original socket. Case reports, case series, cohort studies, and randomized controlled trials have demonstrated the efficacy of ITR in the retention of natural teeth that are untreatable or difficult to manage with root canal treatment or endodontic microsurgery. However, variations in clinical protocols for ITR exist due to the empirical nature of the original protocols and rapid advancements in the field of oral biology and dental materials. This heterogeneity in protocols may cause confusion among dental practitioners; therefore, guidelines and considerations for ITR should be explicated. This expert consensus discusses the biological foundation of ITR, the available clinical protocols and current status of ITR in treating teeth with refractory apical periodontitis or anatomical aberration, and the main complications of this treatment, aiming to refine the clinical management of ITR in accordance with the progress of basic research and clinical studies; the findings suggest that ITR may become a more consistent evidence-based option in dental treatment.
Humans
;
Tooth Replantation/methods*
;
Consensus
;
Periapical Periodontitis/surgery*
10.Theoretical application and suggestions of health communication effect evaluation research
Zicong ZHENG ; Dongying XIE ; Ying ZHANG ; Yangmei HUANG ; Meng WANG ; Wuqi QIU
China Modern Doctor 2025;63(8):79-82
Objective To explore theoretical application of health communication effect evaluation in order to provide support for health communication.Methods Using health communication,health activities,health science popularization,effect evaluation as precise keywords,literature collected by databases from built to May 27,2024 was searched,and literature was screened by removing duplicate literature and reading title and abstract of literature.A total of 121 literatures were selected as research samples.Results Most of literatures did not adopt theoretical framework,and only 33 literatures had theoretical applications,mainly in fields of public health and communication.The most widely used literatures were theory of knowing and believing,Lasswell's 5W mode of communication and theory of persuasion,which were dominated by Western theories and lacked application and innovation of localized theories.Conclusion The future health communication effect evaluation should use more theoretical framework to support research,learn from and integrate theories of different disciplines,and explore localization theory research path.

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