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.Robot-assisted therapy for upper limb of stoke: a bibliometrics analysis
Qing QIN ; Ye LIU ; Haiyan YE ; Chen LI ; Di CHEN
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):85-98
ObjectiveTo analyze the advance of robot-assisted therapy in upper limb functions of patients with stroke. MethodsA search was conducted in the Web of Science Core Collection for literature on the application of robot-assisted therapy in upper limb functions of patients with stroke, from inception to November, 2024. Citespace 6.4.R1 was used to perform bibliometric analysis, including countries of origin, authors, institutions, subject areas, keywords and citation relationships, and knowledge mapping techniques were also utilized. ResultsA total of 198 publications in English were included, showing an upward trend in publication volume. China, Italy and the United States ranked highest in publication counts, with the University Campus Bio-Medico of Rome, Italy contributing the most. Among authors, Giulio Rosati had the highest number of publications. The top three co-occurring keywords were motor recovery, activities of daily living and neuroplasticity. Keywords with the highest citation bursts included rehabilitation robotics, virtual reality and upper limb rehabilitation. Keyword clustering identified four primary research directions: improving upper limb motor function, enhancing sensory function, increasing activities of daily living and promoting brain neuroplasticity. The research spanned several disciplines, including basic medicine, clinical medicine, biomedical engineering, rehabilitation medicine and therapy, and control science and engineering. ConclusionRobot-assisted therapy for the upper limb function in stroke patients constitutes an innovative rehabilitation approach. Current research hotspots focus on both the design of robot-assisted therapy and their effectiveness. Findings suggest that robot-assisted occupational therapy can effectively improve upper limb function, facilitate neuroplasticity, enhance activities of daily living reliant on the upper limbs, and boost patients motivation and confidence in rehabilitation. Future research should emphasize integrating robot-assisted therapy with emerging technologies such as artificial intelligence and virtual reality, to explore its potential in precise rehabilitation strategies and the development of personalized rehabilitation programs.
5.The diagnostic value of endoscopic score based on acetic acid-enhanced narrow-band imaging for gastric intestinal metaplasia
Chen XU ; Zhengyang LI ; Haiyan WANG ; Yuhao WANG ; Xuanguang YE ; Miao JIANG
Chinese Journal of Clinical Medicine 2025;32(3):369-375
Objective To explore the diagnostic value of endoscopic grading of gastric intestinal metaplasia (EGGIM) score under acetic acid-enhanced narrow band imaging (AA-NBI) observation mode for gastric intestinal metaplasia (GIM). Methods A total of 120 patients who underwent gastroscopy at Jinshan Hospital of Fudan University from February 2022 to February 2023 were selected. All patients underwent both white light and AA-NBI endoscopy, with photographic records of intestinal metaplasia in five areas: greater curvature of antrum, lesser curvature of antrum, greater curvature of corpus, lesser curvature of corpus and incisura. EGGIM score was performed: 0 for no intestinal metaplasia, 1 point for focal intestinal metaplasia (GIM area ratio≤30%), 2 points for extensive intestinal metaplasia (GIM area ratio>30%), with a total score of 10 points. Targeted biopsies were performed on suspicious GIM lesions found during endoscopy. If no suspicious GIM lesions were observed, random biopsies were performed according to the updated Sydney system. The pathological histological examination results were staged based on the operative link on gastric intestinal metaplasia assessment (OLGIM) system. The diagnostic value of EGGIM score for OLGIM stage Ⅲ-Ⅳ patients was evaluated using receiver operating characteristic (ROC) curves. Results The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of AA-NBI in detecting GIM were 96.3%, 91.6%, 94.5%, 95.0%, and 93.6%, respectively. The area under the ROC curve for EGGIM diagnosing OLGIM stage Ⅲ-Ⅳ was 0.952 (95%CI 0.914-0.990). The optimal cut-off value for EGGIM was 5 points, with a sensitivity of 96.7% (95%CI 87.6%-99.4%) and specificity of 88.1% (95%CI 76.5%-94.7%). Conclusions EGGIM score (≥5 points) under AA-NBI mode has good diagnostic capability for patients with OLGIM stage Ⅲ-Ⅳ.
6.Evaluation of left ventricular function in patients with pregnancy-induced hypertension using echocardiography
Haiyan YE ; Jianxiang YANG ; Mingming CHEN ; Yuezi ZHAO
Chinese Journal of Primary Medicine and Pharmacy 2024;31(2):180-184
Objective:To investigate the clinical value of tissue Doppler echocardiography in the evaluation of left ventricular function in patients with pregnancy-induced hypertension.Methods:This is a case-control study, including 100 patients with pregnancy-induced hypertension who received treatment at the Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from May 2019 to May 2022, and an additional 100 healthy pregnant women who underwent physical examination during the same period. All participants underwent two-dimensional echocardiography, pulsed Doppler echocardiography, and tissue Doppler echocardiography. Ultrasound parameters related to left ventricular morphology and function were collected from all participants. The ultrasound parameters related to left ventricular morphology and function between patients with different types of pregnancy-induced hypertension and healthy controls were compared. The correlation between left ventricular function ultrasound parameters and serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels was investigated.Results:Patients with pregnancy-induced hypertension, patients with mild preeclampsia, patients with severe preeclampsia, and healthy controls demonstrated differences in interventricular septum thickness during diastole [(10.24 ± 1.18) mm, (11.39 ± 1.24) mm, (11.57 ± 1.29) mm, (8.81 ± 0.95) mm], left ventricular end-diastolic diameter [(47.31 ± 2.81) mm, (49.82 ± 2.89) mm, (52.03 ± 2.94) mm, (46.82 ± 2.76) mm], left ventricular posterior wall thickness [(9.73 ± 1.06) mm, (10.62 ± 1.13) mm, (11.75 ± 1.21) mm, (8.96 ± 0.97) mm], left ventricular inner diameter [(32.82 ± 2.34) mm, (35.48 ± 2.39) mm, (36.04 ± 2.45) mm, (30.41 ± 2.27) mm], and left ventricular mass index [(98.41 ± 7.83) g/m 2, (105.73 ± 8.26) g/m 2, (108.63 ± 8.57) g/m 2, (96.59 ± 7.69) g/m 2]. All of these parameters showed significant differences between patients with different types of pregnancy-induced hypertension and healthy controls ( F = 13.47, 12.61, 16.59, 13.26, 19.73, all P < 0.001). Significant differences were also observed in echocardiographic indices of left ventricular function such as peak velocity ratio of E and A waves, systolic motor amplitude, early peak diastolic velocity to late peak diastolic velocity, and Tei index between patients with different types of pregnancy-induced hypertension and healthy controls ( F = 12.84, 11.27, 14.64, 21.43, all P < 0.001). In patients with pregnancy-induced hypertension, peak velocity ratio of E and A waves, systolic motor amplitude, and early peak diastolic velocity to late peak diastolic velocity were moderately negatively correlated with serum NT-proBNP level ( r = -0.56, -0.43, -0.54, P = 0.029, 0.042, 0.031), while Tei index showed a positive correlation with serum NT-proBNP level ( r = 0.77; P = 0.003). Conclusion:Two-dimensional echocardiography, pulsed Doppler echocardiography combined with tissue Doppler echocardiography can be used to effectively evaluate the changes in left ventricular structure and function in patients with different types of pregnancy-induced hypertension. Monitoring the Tei index using tissue Doppler echocardiography can accurately reflect myocardial injury and functional changes, which has a great clinical application value.
7.Progression,Imaging Characteristics of Left Ventricular Remodeling and the Clinical Value on Decision-making of Intervention in Patients With Aortic Stenosis
Qiaofan CHEN ; Yunqing YE ; Erli ZHANG ; Haiyan XU ; Yongjian WU
Chinese Circulation Journal 2024;39(3):294-300
Aortic stenosis is a valve disease characterized by dynamic and continuous changes in structure and function of left ventricle.Left ventricular remodeling,which embodies pathological changes in myocardial cellular and ventricular geometry,is an important prognostic factor of patients with aortic stenosis.Aortic valve replacement is the only effective treatment for severe aortic stenosis.Current guideline recommendations for interventions are based on symptoms and left ventricular ejection fraction.With the improvements of modern imaging technology,different patterns of remodeling,including hypertrophy and fibrosis,could be identified now.Studies also explored the close association between left ventricular remodeling and function in the setting of aortic stenosis.In this review,we aim to elucidate the characteristic imaging features and potential mechanisms of left ventricular remodeling,and further,we highlight the clinical value of specific imaging features and clinical application of modern imaging methods in the evaluation,risk stratification,and intervention decision-making for patients with aortic stenosis.
8.Serological analysis of severe acute respiratory syndrome coronavirus 2-specific immunoglobulin G antibodies level in Henan Province
Yujiao MU ; Haiyan WEI ; Yafei LI ; Yun SONG ; Shidong LU ; Bicong WU ; Ying YE ; Xueyong HUANG ; Hongxia MA
Chinese Journal of Infectious Diseases 2024;42(2):98-102
Objective:To analyze the specific immunoglobulin G (IgG) antibodies level in the population after the coronavirus disease 2019 (COVID-19) pandemic in Henan Province.Methods:A total of 5 178 peripheral venous blood samples were collected from 10 districts (counties) in Henan Province according to the national seroepidemiological survey program for COVID-19, and the method of cluster random sampling was adopted from March 6 to 15, 2023. Descriptive analysis was used for the basic data, history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, SARS-CoV-2 infection of the respondents. The specific IgG antibody of SARS-CoV-2 was detected using chemiluminescence method. Statistical analysis was performed by using rank sum test, Kruskal Wallis test, and Dunn′s test.Results:The overall positive rate of SARS-CoV-2-specific IgG antibody was 83.35%(4 316/5 178). There were statistically significant differences in the specific IgG antibodies against SARS-CoV-2 produced by people of different sexes, different ages, infected or not, vaccinated or not, and vaccinated with different doses of SARS-CoV-2 vaccine ( Z=3.60, H=195.32, Z=6.10, 18.08, H=382.70, respectively, all P<0.001). The specific IgG antibodies produced by unvaccinated+ uninfected group, unvaccinated+ infected group, vaccinated+ uninfected group, and vaccinated+ infected group were 3.54(0.98, 11.00), 60.65(2.33, 84.80), 133.00(59.80, 173.00), and 142.00(98.30, 176.00), respectively. And the difference was statistically significant( H=354.62, P<0.001). The specific IgG antibodies of uninfected people increased with the increase of inoculum times( H=287.00 and 98.48, both P<0.001). The specific IgG antibodies of people who were not infected with SARS-CoV-2 in the groups of whose interval from the last inoculation of SARS-CoV-2 vaccine to blood collection was less than three months, three to six months and more than six months were 171.86(156.04, 196.57), 71.71(17.08, 110.38) and 132.14(57.59, 172.25), respectively, and the difference was statistically significant ( H=19.93, P<0.001). Among them, the absolute difference between the less than three months group and the three to six months group was statistically significant ( Z=3.67, P<0.001), and the absolute difference between the less than three months group and the more than six months group was statistically significant ( Z=3.47, P<0.001). The specific IgG antibodies level in the less than three months group was the highest. Conclusions:There is a certain correlation between the number of SARS-CoV-2 vaccine doses and the specific IgG antibodies level in uninfected people. The specific IgG antibodies could maintain a high level for three months after immunization.
9.Determination of chloride,sulfate and bicarbonate ions in Compound polyethylene glycol electrolyte powder (Ⅲ) by ion chromatography
Xianhua ZHANG ; Yuxin ZHAO ; Haiyan ZHOU ; Xiaolu ZHU ; Dengyan LAI ; Jiao ZHU ; Tao PENG ; Shichun YE
China Pharmacy 2024;35(22):2769-2772
OBJECTIVE To establish an ion chromatography method for the simultaneous determination of chloride, sulfate and bicarbonate ions in Polyethylene glycol electrolyte powder (Ⅲ). METHODS The chromatographic column was a Dionex IonpacTM AS11-HC anion analysis column, with a Dionex IonPacTM AG11-HC guard column. The mobile phase was 10 mmol/L potassium hydroxide at an isocratic elution flow rate of 1.2 mL/min. The detector was a conductivity detector, and the suppressor was a Dionex AERS with a suppressor current of 30 mA. The column temperature was maintained at 30 ° C, and the injection volume was 10 μL. Chloride and sulfate contents were calculated by external standard method, while bicarbonate content was determined by double logarithmic fitting standard curve method. RESULTS Under these chromatographic conditions, chloride, sulfate and bicarbonate ions were effectively separated with linear ranges of 0.055 to 0.219 mg/mL (r=0.999 9), 0.155 to 0.618 mg/mL (r=1.000 0), and 0.065 to 0.121 mg/mL (r=0.999 9), respectively. The recoveries were 98.06% to 101.34%, 97.37% to 101.25%, and 97.16% to 99.81%, respectively, with RSDs of 1.1%, 1.3% and 1.0% (n=9). The RSDs for the evaluation of precision, accuracy, stability and ruggedness were all less than 2%. CONCLUSIONS The established ion chromatography is simple, rapid, accurate, precise and durable, can simultaneously determine the contents of chloride, sulfate and bicarbonate ions in Polyethylene glycol electrolyte powder (Ⅲ), which is suitable for its quality control.
10.Theoretical framework of rehabilitation big data based on ICF
Yifan TIAN ; Di CHEN ; Yaning CHENG ; Haiyan YE ; Ye LIU ; Yingxin ZHANG ; Xueli LÜ
Chinese Journal of Rehabilitation Theory and Practice 2024;30(9):1043-1052
Objective To construct the theoretical framework of rehabilitation big data based on International Classification of Func-tioning,Disability and Health(ICF). Methods Drawing upon international rehabilitation policy documents,such as the World Health Organization's Rehabili-tation in health systems;Rehabilitation in health systems:guide for action;Rehabilitation indicator menu:a tool accompanying the Framework for Rehabilitation Monitoring and Evaluation(FRAME);Template for Rehabilita-tion Information Collection(TRIC):a tool accompanying the Systematic Assessment of Rehabilitation Situation(STARS);and Framework and Standards for Country Health Information Systems;this study examined the com-position and function of rehabilitation big data.The content structure of the rehabilitation big data domain was an-alyzed using the World Health Organization Family of International Classifications(WHO-FICs).Furthermore,the generation patterns of rehabilitation big data was constructed drawing on the Health Metrics Network and big data hierarchical classification. Results Within the six primary elements of the health service system,the information system element was particularly significant,encompassing a substantial branch known as rehabilitation big data.There were three components of rehabilitation big data:health condition,health-related factors and health services.The content framework for this data was derived from the WHO-FICs framework,which covered three dimensions:health and function,dis-ease and function,and disease,function and intervention.A comprehensive model for generating and applying re-habilitation big data in rehabilitation services was developed in line with the requirements for constructing big da-ta architectures.The sources of this data included population censuses,social registration information,population surveys,resources,services and personal records.The result chain of rehabilitation big data encompassed five major processes:input,process,output,outcome and impact.The processing and utilization of this data involved collection,storage,management,analysis and application. Conclusion A theoretical framework for rehabilitation big data has been constructed based on the ICF theory.

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