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.Establishment and evaluation of induced model of meibomian gland dysfunction in rats through eyeliner tattoo
Fen HU ; He WANG ; Kai ZHAO ; Shuwen CHEN ; Qiuchen LU ; Qian LIU ; Mingxin LI
International Eye Science 2024;24(8):1200-1206
AIM:To establish a model of meibomian gland dysfunction in rats induced by eyeliner tattoo and investigate its potential mechanisms.METHODS:A total of 40 SD rats were selected, with 30 randomly chosen to have eyeliner tattoo applied their right eyes and designated as the eyeliner group. The remaining 10 rats were not given any treatment and served as the normal group. The corneal morphology of both groups was observed using a slit lamp at 1, 2, and 4 wk after establishment, and the tear film break-up time(BUT), Schirmer I test(SIt), corneal fluorescein staining score, and corneal irregularity score were calculated. The corneal Placido rings were examined using an ocular surface analyzer, and the corneal tissue structures of both groups were observed under a confocal microscope. After 4 wk and completion of clinical indicator recording, the eyeballs and upper and lower eyelid tissues were taken for pathological examination. The meibomian gland structures were observed through HE staining, the conjunctival goblet cells were observed using PAS staining, and the lipid droplets were observed with ORO staining.RESULTS:The slit lamp examination results showed that the eyeliner group rats exhibited in situ black pigmentation in the eyelids, with no eyelid deformation or scarring. The corneal epithelium was rough, with positive fluorescein staining, presenting as spotty staining that worsened over time. Compared with the normal group, the BUT was significantly shortened, tear secretion volume was significantly decreased, and the corneal fluorescein staining score and corneal irregularity score were significantly increased at 1, 2, and 4 wk after modeling in the eyeliner group(all P<0.01). The corneal confocal microscopy results showed a decrease in corneal epithelial cells in the eyeliner group, with the appearance of abnormally bright cells, and inflammatory cell infiltration visible in the stromal layer. The ORO staining results revealed a decrease in lipid droplets in the eyeliner group, showing a downward trend with increasing observation time. The HE staining results showed that pigment blocked the meibomian gland openings in the eyeliner group, and the density of meibomian gland acini showed a downward trend over time. The PAS staining results showed a decreasing trend in the number of PAS-positive cells in the eyeliner group.CONCLUSION:Eyeliner tattoo can induce meibomian gland dysfunction, and the blockage of meibomian gland openings caused by the pigment particles used may be an important cause of meibomian gland dysfunction.
5.Mechanism of Action of Coptidis Rhizoma and Ophiopogonis Radix in Delaying Diabetic Nephropathy Based on EGFR/PI3K/Akt Signaling Pathway
Shaoyu LI ; Man GONG ; Qiufang LI ; Liping DAI ; Guiqun WANG ; Qiuchen YANG ; Qiongqiong ZHANG ; Erping XU ; Yalin LIU
Chinese Journal of Experimental Traditional Medical Formulae 2024;30(20):22-29
ObjectiveTo observe the effect of Coptidis Rhizoma and Ophiopogonis Radix on renal tissue injury and epidermal growth factor receptor (EGFR)/phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway in rats with diabetic nephropathy (DN) and explore its possible mechanism of delaying DN. MethodThirty-six male Wistar rats were randomly divided into a normal group (6 rats) and a model group (30 rats). The model group was fed with a high-fat and high-sugar diet combined with streptozotocin (STZ) to establish a rat model of type 2 diabetes. After the successful preparation of the model, the rats were randomly divided into the model group, low, medium, and high dose groups of Coptidis Rhizoma and Ophiopogonis Radix (100, 200, 400 mg·kg-1), and metformin group (200 mg·kg-1). After administration, the levels of fasting blood glucose (FBG), 24 h urine protein (24 h-UTP), creatinine (SCr), urea nitrogen (BUN), and uric acid (UA) were detected. Hematoxylin-eosin (HE) staining and Masson staining were used to observe the pathological changes of renal tissue in rats. Western blot and Real-time fluorescence quantitative polymerase chain reaction (Real-time PCR) were used to detect the related protein expression of EGFR, PI3K, and Akt and their mRNA expression levels in the renal tissue of rats in each group. ResultsCompared with the normal group, the levels of FBG, SCr, BUN, UA, 24 h-UTP, and kidney index in the model group were significantly increased (P<0.01), most renal tubular epithelial cells were necrotic, and the content of collagen in glomeruli was significantly increased (P<0.01). Compared with the model group, the above indexes of rats in each administration group were improved to varying degrees. The FBG, SCr, BUN, UA, 24 h-UTP, and kidney index of rats in each dose group and metformin group were significantly decreased (P<0.01, P<0.05). The necrosis degree of renal tubular epithelial cells was reduced, and the fibrosis area was decreased (P<0.01). There related protein and mRNA expressions of EGFR, PI3K, and Akt were significantly increased (P<0.05, P<0.01). ConclusionCoptidis Rhizoma and Ophiopogonis Radix can alleviate renal tissue injury in rats with DN, and their mechanism may be related to the regulation of the EGFR/PI3K/Akt signaling pathway.
6.Identification of Chemical Components and Components Absorbed into Blood of Sishen Pills
Qiuchen YANG ; Qiongqiong ZHANG ; Fang WANG ; Erping XU ; Liping DAI ; Ying CUI ; Lingling LI ; Yan-Ing ZHANG ; Yalin LIU
Journal of Nanjing University of Traditional Chinese Medicine 2024;40(11):1234-1249
OBJECTIVE To identify and classify the chemical components and components absorbed into blood of Sishen Pills u-sing ultra-high performance liquid chromatography-quadrupole-orbitrap high resolution mass spectrometry.METHODS SD rats were divided into blank group and drug administration group.The rats in drug administration group were given water extract of Sishen Pills formula intragastrically,and blank and drug-containing plasma were collected respectively.A Hypersil GOLD VANQUISH column(2.1 mm×100 mm,1.9 μm)was used,with 0.1%formic acid water acetonitrile as the mobile phase,gradient elution,volume flow rate of 0.3 mL·min-1,and column temperature of 35℃.Electrospray ion source(ESI)with positive and negative ion scanning mode was used for chromatographic separation and mass spectrometry data acquisition.The chemical components of Sishen Pills were identi-fied by comparing the exact molecular mass,fragment ion information and relative retention time with the map of reference substance,matching with the self-established database and combining with literature reports.On this basis,the components absorbed into blood of Sishen Pills were analyzed by comparing the blank plasma and drug-containing plasma.RESULTS A total of 181 chemical compo-nents were identified from Sishen Pills,mainly including flavonoids,alkaloids,lignans and other components.A total of 49 prototype blood components were identified from the plasma samples,mainly including flavonoids,alkaloids and other components.CONCLU-SION A variety of chemical components in Sishen Pills and drug-containing plasma are comprehensively,accurately and quickly i-dentified,and all of them are assigned to the various medicinal materials in the prescription.This study provides reference for the qual-ity control,basic research on medicinal effect materials and clinical application of Sishen Pills.
7.Effect of Botulinum Toxin A Combined with Exercise Program Sit-to-stand Training on Lower Limb Spasticity and Balance Ability in Pa-tients with Stroke
Jing LIU ; Qiuchen QIAN ; Qing HE
Journal of Medical Research 2024;53(6):109-113
Objective To observe the effect of botulinum toxin A combined with exercise program sit-to-stand training on lower limb spasticity and balance ability in patients with stroke.Methods A total of 84 patients with stroke admitted to our hospital from Janu-ary 2020 to December 2021 were randomly divided into control group(n=42)and treatment group(n=42).The control group was trea-ted with the exercise program sit-to-stand training alone.The treatment group was treated with botulinum toxin A combined with exer-cise program start-up training.The modified Ashworth scale(MAS),Fugl-Meyer assessment(FMA),Berg balance scale(BBS),Barthel index(BI),and stroke-specific quality of life(SS-QOL)were compared between the two groups before treatment,and 4,8,and 12 weeks after treatment.Results No significant difference in clinical baseline data was found between the two groups(P>0.05).The MAS of the two groups at 4,8 and 12 weeks after treatment was significantly lower,while the FMA,BBS,BI,and SS-QOL were significantly higher than those before treatment(P<0.05).Compared with the control group,the improvement of MAS,FMA,BBS,BI,and SS-QOL at 4,8 and 12 weeks after treatment was better than those in the control group(P<0.05).Conclusion Botulinum toxin A combined with exercise program sit-to-stand training can significantly alleviate lower limb spasticity in patients with stroke,improve motor function and balance ability,and improve the ability of daily life and quality of life,which is worthy of clinical promotion and appli-cation.
8.Comparative effect of different neuromuscular exercises on pain and motor function of knee in patients with early knee osteoarthritis
Guancong ZHANG ; Qiuchen HUANG ; Rui GU ; Sihai LIU ; Chunying HU ; Kemin LIU
Chinese Journal of Rehabilitation Theory and Practice 2023;29(9):1090-1097
ObjectiveTo compare the effect of proprioceptive neuromuscular training methods on pain and motor ability of knee in patients with early knee osteoarthritis (KOA) . MethodsFrom November, 2022 to May, 2023, 60 early KOA patients from Beijing Bo'ai Hospital and community were randomly divided into groups A, B and C, with 20 patients in each group. Group A received proprioceptive neuromuscular facilitation (PNF), group B received neuromuscular exercise (NEMEX), and group C received PNF and NEMEX, for six weeks. They were assessed with Visual Analogue Scale for pain (VAS), angle reappearance test, difference of pre-motor reaction time (VM-VL), active range of motion (AROM) of knee flexion, 10-meter walk test (10MWT), and Knee Injury and Osteoarthritis Outcome Score (KOOS) before and after treatment. ResultsAll the indexes improved in all the groups after treatment (|t| > 2.532, P < 0.05). Among the groups, the VAS score was the least in group A, and then groups C and B; the angle reappearance error was the least in group C, and similar in groups A and B; the VM-VL was the least in groups A and C, followed by group B. ConclusionPNF, NEMEX and PNF+NEMEX can relieve the pain and improve the motor function of knee in patients with early KOA, however, PNF is the most effective on relieving pain, and PNF+NEMEX is the most effective on improving knee function.
9.Characterastics of muscle architectural parameters for early knee osteoarthritis in middle-aged and elderly women
Lili YU ; Qiuchen HUANG ; Zhigang CUI ; Desheng LI ; Chunying HU ; Miao YE ; Kemin LIU
Chinese Journal of Rehabilitation Theory and Practice 2023;29(3):356-363
ObjectiveTo observe the architectural parameter changes of the muscles around the knee in middle-aged and elderly women with early knee osteoarthritis (KOA) by musculoskeletal ultrasound, and to clarify the indicators of muscles that affect early KOA. MethodsFrom January to August, 2022, 20 healthy middle-aged and elderly healthy women (controls) and 20 middle-aged and elderly women with unilateral early KOA (KOA group) were recruited through Beijing Bo'ai Hospital, to measure muscle thickness of the popliteus muscle, the muscle thickness and the pennation angle of the quadriceps, as rectus femoris, vastus intermedius, vastus lateralis, vastus medialis longus and vastus medialis oblique. ResultsCompared with the healthy limb of KOA group, and the controls, the muscle thickness of vastus medialis longus, vastus medialis oblique and popliteus muscle of the affected limb of KOA group became thinner (t > 2.133, P < 0.05); the proportion of thickness of vastus medialis oblique to thickness of vastus lateralis became smaller (t > 3.660, P < 0.05). The pennation angle was smaller in the affected limb of KOA group than in the matched dominant side of the controls (t = 3.101, P < 0.05). Logistic regression analysis showed that the muscle thickness of vastus medialis oblique (OR = 0.235, 95%CI 0.068 to 0.805, P = 0.021) and popliteus muscle (OR = 0.387, 95%CI 0.152 to 0.980, P = 0.045) were related to the onset of early KOA. ConclusionThe thickness of vastus medialis longus, vastus medialis oblique and popliteus muscle decrease, and the balance of the strength of vastus medialis oblique and vastus lateralis weakens in the affected limbs of the middle-aged and elderly women with early KOA. The thickness of vastus medialis oblique and popliteus muscle are protective factors for onset of KOA.
10.Research progress of sarcopenia as a prognostic marker of genitourinary tumors
Jiajian YANG ; Qiuchen LIU ; Hengxi JIN ; Yuxin LIN ; Zheng ZHOU ; Jinxian PU
Chinese Journal of Urology 2022;43(5):389-392
Sarcopenia is observed to have age-related loss of skeletal muscle mass, muscle strength and physical performance, which can be an effective prognostic indicator for postoperative complications and poor survival outcomes in tumor patients. Sarcopenia could reflect tumor-host interactions and has the advantages in accuracy and generality compared with traditional predictors. This paper reviews the research progress of sarcopenia in predicting the prognosis of genitourinary tumors.

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