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.
8.Protective Effect of Qiling Prescription on Rats with Chronic Atrophic Gastritis Combined with Gastric Intestinal Metaplasia Via PI3K/Akt Pathway
Xiangming HUANG ; Xinyu FAN ; Min LU
Chinese Journal of Experimental Traditional Medical Formulae 2024;30(22):79-86
ObjectiveTo explore the potential mechanism of Qiling prescription in intervening in chronic atrophic gastritis with gastric intestinal metaplasia (GIM). MethodThe 80 SPF-grade SD rats were randomly divided into the following eight groups (10 rats per group): blank group, blank + Qiling prescription group, model group, high-dose Qiling prescription group, medium-dose Qiling prescription group, low-dose Qiling prescription group, folic acid group, and morodan group. Except for the blank and blank + Qiling prescription groups, the other groups underwent modeling by intragastric administration of 0.02 mol·L-1 N-methyl-N′-nitro-N-nitrosoguanidine (MNNG) solution combined with irregular feeding. After successful modeling, the blank and model groups were given distilled water, the blank + Qiling prescription group, and high, medium, and low-dose Qiling prescription groups were given Qiling prescription water decoction at 7.60, 15.21, 7.60, 3.80 g·kg-1, respectively, the folic acid group was given folic acid suspension at 0.002 g·kg-1, the morodan group was given morodan suspension at 1.40 g·kg-1 by gavage once a day for 8 weeks. The general condition and body weight of the rats were observed during the experiment. Hematoxylin-eosin (HE) staining was performed on gastric tissues. Immunohistochemistry (IHC) was used to detect the levels of mucin 2 (MUC2) and caudal-type homeobox transcription factor 2 (CDX2) in gastric tissues. Enzyme-linked immunosorbent assay (ELISA) was used to measure the serum levels of interleukin-6 (IL-6), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), cysteine-aspartic protease-3 (Caspase-3), phosphatidylinositol 3-kinase (PI3K), and protein kinase B (Akt). Western blot analysis was performed to detect the expression and phosphorylation levels of PI3K and Akt in gastric tissues. ResultAnimal experiments showed that compared to the blank group, the rats in the model group had a trend of weight loss starting from week 16. Compared to the model group, high and medium doses of Qiling prescription improved the mental state and body weight of the rats. Pathological results at week 24 showed successful modeling with reduced gastric mucosal glandular cells and disordered arrangement in the model group compared to the blank group. The high and medium-dose Qiling prescription groups showed significantly fewer or absent goblet cells, indicating improved gastric mucosal pathology as compared to model group. Compared to blank group, the model group showed increased levels of MUC2 and CDX2 in gastric tissues (P<0.01). High and medium doses of Qiling prescription significantly reduced the levels of MUC2 and CDX2 in gastric tissues compared to the model group (P<0.05,P<0.01). Compared to the blank group, the model group had increased serum levels of IL-6, IL-1β, TNF-α, Caspase-3, PI3K, and Akt (P<0.05). Compared with the model group, high-dose Qiling prescription significantly reduced the serum levels of IL-1β, Caspase-3, PI3K, and Akt (P<0.01), medium-dose significantly reduced the levels of IL-6, IL-1β, TNF-α, Caspase-3, PI3K, and Akt (P<0.05,P<0.01). Compared to the blank group, the model group showed significantly increased expression of PI3K and Akt in gastric tissues. High-dose Qiling prescription significantly inhibited Akt protein expression compared to the model group (P<0.01). ConclusionQiling prescription may alleviate GIM and delay inflammation-cancer transformation through multi-component, multi-target, and multi-pathway mechanisms by inhibiting the PI3K/Akt pathway, reducing the release of pro-inflammatory factors, and inhibiting gastric mucosal epithelial cell apoptosis.
9.Measurement and analysis of peak skin dose for patients withinterventional cardiology procedures
Qiaoqiao ZHAO ; Yaohua FAN ; Zhuo HUANG ; Hui XU ; Xiangming OU
Chinese Journal of Radiological Health 2024;33(3):229-233
Objective :
To obtain the peak skin dose (PSD) of patients with interventional cardiology procedures and toevaluate the risk of deterministic effects.
Methods :
Gafchromic XR RV3 films were used in a Level A tertiary hospital inBeijing to measure the PSD of patients who underwent interventional cardiology procedures. The measurement focused onfour common types of procedures, including coronary angiography, percutaneous transluminal coronary angioplasty,cathet-er radiofrequency ablation, and congenital heart disease. The films were scanned by EPSON EXPRESSION 10000XL andanalyzed by FILM QA ProTM 2014 software.
Results :
PSD was measured in 59 patients with interventional cardiologypro-cedures, including 23 with coronary angiography, 21 with percutaneous transluminal coronary angioplasty, 9 with catheterradiofrequency ablation, and 6 with congenital heart disease. The seven patients with PSD ≥ 2 Gy all underwentpercu-taneous transluminal coronary angioplasty, one with PSD > 3 Gy and six with PSD < 2 Gy.
Conclusion
The PSD of somepatients with interventional cardiology surgery exceeded the dose threshold of deterministic effects recommended by theICRP 118. There is a risk of deterministic effects in interventional cardiology surgery, especially in patients withpercu-taneous transluminal coronary angioplasty.
10.The therapeutic effect of low-dose methimazole on hyperthyroidism patients and its impact on thyroid volume and calcitonin levels
Jing HUANG ; Wenchun YE ; Xiangming FANG ; Yan QIAO ; Juan LI
Journal of Chinese Physician 2024;26(4):560-563
Objective:To analyze the effects of low-dose methimazole treatment on thyroid volume and calcitonin levels in patients with hyperthyroidism.Methods:A total of 100 hyperthyroidism patients who were treated at the Mianyang Central Hospital from January to June 2019 were selected and randomly divided into a control group (50 cases) and an observation group (50 cases) using a random number table method. The control group was treated with once a day and 30 mg/dose of methimazole, while the observation group was treated with twice a day and 10 mg/dose of methimazole. Thyroid volume, and thyroid function [Thyroid growth hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone receptor antibody (TRAb)] before and after treatment in two groups of patients, the changes in serum levels of calcitonin (CT), visfatin, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were compared. The clinical efficacy of two groups were also compared.Results:The total clinical effective rate of the observation group was higher than that of the control group ( P<0.05). After treatment, the thyroid volume in the observation group was significantly smaller than that in the control group, and the CT level was significantly lower than that in the control group (all P<0.05). After treatment, the TSH level in the observation group was significantly higher than that in the control group, while the levels of FT3, FT4, and TRAb were significantly lower than those in the control group (all P<0.05). After treatment, the levels of Visfatin, TNF-α, and IL-6 in the observation group were significantly lower than those in the control group (all P<0.05). Conclusions:Low dose methimazole can improve thyroid function, reduce thyroid volume, lower body CT and inflammation levels in patients with hyperthyroidism, and has a better therapeutic effect.

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