1.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.
2.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.
3.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.
4.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.
5.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.
6.Herbal Textual Research on Malvae Semen in Famous Classical Formulas
Dongxue CHEN ; Yibo LIU ; Yangyang YU ; Guoshuai LYU ; Huili WU ; Xinle HAN ; Yue TAN ; Minhui LI ; Zhilai ZHAN
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(7):252-264
The medicinal use of Malvae Semen has a long history. In this paper, by consulting the ancient materia medica, prescription, agronomy, literature and other aspects of the classics, the name, origin, evolution of scientific name, quality, harvesting and processing, functions and indications and others of Malvae Semen were systematically sorted out and verified, so as to provide a basis for the development and utilization of famous classical formulas containing this herb. According to the textual research, Shennong Bencaojing began to use Dongkuizi as the correct name, which was used in the past dynasties, and there were also aliases such as Kuicaizi, Huacai, and Kuizi. Through the original research, it can be seen that Kuicai is the mainstream original plant of Malvae Semen, that is, Malva verticillata var. crispa, the Alcea rosea and M. cathayensis are also used. In modern times, the seeds of Abutilon theophrasti have been passed off as Malvae Semen, while the seeds of M. verticillata var. crispa have rarely been used in medicine. And Abutili Semen has been another medicinal material with different efficacy since the collection of Newly Revised Materia Medica in the Tang dynasty. Since the Ming and Qing dynasties, the cultivation of Kuicai has been decreasing, while A. theophrasti is more common and easy to obtain, and Abutili Semen and Malvae Semen are similar in morphology and confused, which should be corrected. In addition, Malvae Fructus is a Mongolian customary medicinal herb, which is different from the traditional use of seeds in traditional Chinese medicine. Kuicai, as an important vegetable in history, was widely cultivated and gradually shrunk after the Song dynasty, it is now mainly produced in southern provinces. The quality evaluation of Malvae Semen is better for those with dry bodies, full grain, grayish brown color, no mud, and no impurities. The harvesting is generally in the autumn and winter. After drying, it is seeded, sieved peel and impurities, mashed, or slightly stir-fried to yellow-white color with gentle fire. It is sweet, cold and slippery in nature and taste, with the main effects of laxation, diuresis, lactation and elimination of swelling. The efficacy of Abutili Semen is clearing heat and removing toxicity, promoting diuresis and removing nebula, the efficacy is quite different from that of Malvae Semen. Based on the results of textual research, it is suggested that M. verticillata var. crispa should be used as the medicinal source of Malvae Semen in the development of famous classical formulas, the corresponding processing methods should be selected according to the requirements of drug processing in the formulas, while the raw products are recommended to be used if the processing is not specified.
7.Herbal Textual Research on Malvae Semen in Famous Classical Formulas
Dongxue CHEN ; Yibo LIU ; Yangyang YU ; Guoshuai LYU ; Huili WU ; Xinle HAN ; Yue TAN ; Minhui LI ; Zhilai ZHAN
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(7):252-264
The medicinal use of Malvae Semen has a long history. In this paper, by consulting the ancient materia medica, prescription, agronomy, literature and other aspects of the classics, the name, origin, evolution of scientific name, quality, harvesting and processing, functions and indications and others of Malvae Semen were systematically sorted out and verified, so as to provide a basis for the development and utilization of famous classical formulas containing this herb. According to the textual research, Shennong Bencaojing began to use Dongkuizi as the correct name, which was used in the past dynasties, and there were also aliases such as Kuicaizi, Huacai, and Kuizi. Through the original research, it can be seen that Kuicai is the mainstream original plant of Malvae Semen, that is, Malva verticillata var. crispa, the Alcea rosea and M. cathayensis are also used. In modern times, the seeds of Abutilon theophrasti have been passed off as Malvae Semen, while the seeds of M. verticillata var. crispa have rarely been used in medicine. And Abutili Semen has been another medicinal material with different efficacy since the collection of Newly Revised Materia Medica in the Tang dynasty. Since the Ming and Qing dynasties, the cultivation of Kuicai has been decreasing, while A. theophrasti is more common and easy to obtain, and Abutili Semen and Malvae Semen are similar in morphology and confused, which should be corrected. In addition, Malvae Fructus is a Mongolian customary medicinal herb, which is different from the traditional use of seeds in traditional Chinese medicine. Kuicai, as an important vegetable in history, was widely cultivated and gradually shrunk after the Song dynasty, it is now mainly produced in southern provinces. The quality evaluation of Malvae Semen is better for those with dry bodies, full grain, grayish brown color, no mud, and no impurities. The harvesting is generally in the autumn and winter. After drying, it is seeded, sieved peel and impurities, mashed, or slightly stir-fried to yellow-white color with gentle fire. It is sweet, cold and slippery in nature and taste, with the main effects of laxation, diuresis, lactation and elimination of swelling. The efficacy of Abutili Semen is clearing heat and removing toxicity, promoting diuresis and removing nebula, the efficacy is quite different from that of Malvae Semen. Based on the results of textual research, it is suggested that M. verticillata var. crispa should be used as the medicinal source of Malvae Semen in the development of famous classical formulas, the corresponding processing methods should be selected according to the requirements of drug processing in the formulas, while the raw products are recommended to be used if the processing is not specified.
8.A prediction model for high-risk cardiovascular disease among residents aged 35 to 75 years
ZHOU Guoying ; XING Lili ; SU Ying ; LIU Hongjie ; LIU He ; WANG Di ; XUE Jinfeng ; DAI Wei ; WANG Jing ; YANG Xinghua
Journal of Preventive Medicine 2025;37(1):12-16
Objective:
To establish a prediction model for high-risk cardiovascular disease (CVD) among residents aged 35 to 75 years, so as to provide the basis for improving CVD prevention and control measures.
Methods:
Permanent residents aged 35 to 75 years were selected from Dongcheng District, Beijing Municipality using the stratified random sampling method from 2018 to 2023. Demographic information, lifestyle, waist circumference and blood biochemical indicators were collected through questionnaire surveys, physical examinations and laboratory tests. Influencing factors for high-risk CVD among residents aged 35 to 75 years were identified using a multivariable logistic regression model, and a prediction model for high-risk CVD was established. The predictive effect was evaluated using the receiver operating characteristic (ROC) curve.
Results:
A total of 6 968 individuals were surveyed, including 2 821 males (40.49%) and 4 147 females (59.51%), and had a mean age of (59.92±9.33) years. There were 1 155 high-risk CVD population, with a detection rate of 16.58%. Multivariable logistic regression analysis showed that gender, age, smoking, central obesity, systolic blood pressure, fasting blood glucose, triglyceride and low-density lipoprotein cholesterol were influencing factors for high-risk CVD among residents aged 35 to 75 years (all P<0.05). The area under the ROC curve of the established prediction model was 0.849 (95%CI: 0.834-0.863), with a sensitivity of 0.693 and a specificity of 0.863, indicating good discrimination.
Conclusion
The model constructed by eight factors including demographic characteristics, lifestyle and blood biochemical indicators has good predictive value for high-risk CVD among residents aged 35 to 75 years.
9.Pharmacokinetic Analysis of Ziyuglycoside Ⅰ in Normal and Acute Kidney Injury Rats
Yunhui ZHANG ; Yanli LIU ; Qiongming XU ; Shuding SUN ; Hongjin ZHU ; Di ZHAO ; Suxiang FENG
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(5):203-210
ObjectiveBased on ultra-high performance liquid chromatography-quadrupole-electrostatic field orbital trap-linear ion-trap mass spectrometry(UPLC-Orbitrap Fusion Lumos Tribrid-MS), the plasma concentration of ziyuglycoside Ⅰ was determined at different time points after oral administration, and its pharmacokinetic characteristics in normal rats and rats with acute kidney injury were compared. MethodsRats were randomly divided into normal group and model group, the model group received intraperitoneal cisplatin(10 mg·kg-1) to establish the acute kidney injury model, the normal group was given the same volume of saline. After successful modeling, rats in the normal and model groups were randomly divided into the normal low, medium and high dose groups(2.5, 5, 7.5 mg·kg-1) and the model low, medium and high dose groups(2.5, 5, 7.5 mg·kg-1), 6 rats in each group, and the plasma was collected at different time points after receiving the corresponding dose of ziyuglycoside Ⅰ. Then, the concentration of ziyuglycoside Ⅰ in rat plasma was determined by UPLC-Orbitrap Fusion Lumos Tribrid-MS, and the drug-time curve was poltted. The pharmacokinetic parameters were calculated by Kinetica 5.1 software, and the differences in pharmacokinetic parameters between different administration groups were compared by independent sample t-test with SPSS 22.0. ResultsThe pharmacokinetic results showed that after receiving the different doses of ziyuglycoside Ⅰ, its concentration increased first and then decreased, and all of them reached the maximum plasma concentration at about 0.5 h. The area under the curve(AUC0-t) and mean retention time(MRT0-t) of normal and model rats increased with the increased dose, and the clearance(CL) decreased with the increasing dose. Compared with the normal group, the AUC0-t was significantly increased(P<0.01), peak concentration(Cmax) and CL decreased in model rats at different doses, indicating that the physiological state of the rats could affect the absorption and elimination of ziyuglycoside Ⅰ in vivo. ConclusionThe pharmacokinetic characteristics of ziyuglycoside Ⅰ are quite different in normal rats and acute kidney injury model rats, which may be due to the change of the body environment in the pathological state, then lead to changes in absorption and metabolic processes.
10.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.


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