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.Relationship of selfinjurious behavior with peer discrimination and depression among AIDS orphans
ZHANG Yifan, KONG Beibei, YANG Meng
Chinese Journal of School Health 2024;45(9):1324-1327
Objective:
To explore the relationship of self-injurious behavior with peer discrimination and depression among AIDS orphans, so as to provide the basis for promoting the mental health of AIDS orphans.
Methods:
From March 2021 to March 2022, 626 AIDS orphans from 5 counties in Henan Province were selected by stratified cluster random sampling methods. Non suicidal Self-injury assessment Tool, Discrimination Experience Scale, and Zung Self-rating Depression Scale were used to investigate AIDS orphans self-injurious behavior, peer discrimination and depression. Multivariate Logistic regression model was used to analyze the relationship between self-injurious behavior and peer discrimination of AIDS orphans. Multivariate linear regression analysis was used to explore the moderating effect of depression between self-injurious behavior and peer discrimination of AIDS orphans.
Results:
The detection rates of self-injurious behavior, peer discrimination and depression of AIDS orphans were 80.0%, 73.3% and 67.6 % respectively. The detection rates of the three items mentioned above were 86.9%, 81.5%, and 77.5% for double orphaned children, respectively, which were higher than 74.6%, 67.0%, and 59.8% for single orphaned children, and the differences were statistically significant ( χ 2=21.29, 23.78, 14.23, P <0.01). The score of self-injurious behavior of AIDS orphans was positively correlated with peer discrimination and depression ( r=0.55, 0.40, P <0.01). Depression played a moderating role in the relationship between self-injurious behavior and peer discrimination of AIDS orphans ( β= 0.03, P <0.05).
Conclusions
AIDS orphans are more likely to engage in self-injurious behaviors after experiencing peer discrimination and psychological depression. The society and schools should adopt targeted intervention strategies to promote the mental health among AIDS orphans.
6.Analysis of the short-term efficacy and safety of percutaneous liver puncture in the local treatment of portal vein thrombosis
Ting CUI ; Tao WANG ; Bing ZHU ; Mingming MENG ; Bowen LIU ; Yifan LÜ ; Quan CHEN ; Yifan WU ; Yu ZHANG ; Chengbin DONG ; Fuquan LIU
Journal of Practical Radiology 2024;40(8):1338-1341
Objective To evaluate the short-term efficacy and safety of percutaneous liver puncture for local management of portal vein thrombosis(PVT).Methods Variations in thrombus,blood flow,and laboratory examination results were observed before and after percutaneous liver puncture in 197 patients with PVT,and the occurrence of comorbidities was recorded and followed up for one year after treatment.Results After treatment,the thrombus in the main portal vein vessels almostly disappeared in 119 patients(60.41%)with PVT,the thrombus had a significant reduction in 57 patients(28.93%),and the thrombus had a smaller change or an increase in 21 patients(10.66%);146 patients(74.11%)had smooth blood flow in the main portal vein vessels,29 patients(14.72%)showed significant improvement in blood flow,and 22 patients(11.17%)showed no significant improvement or worsening of blockage.The mean portal venous pressure was significantly lower than that before treatment(P<0.001);thrombin time,activated partial thromboplastin time,and prothrombin time were prolonged compared to those before thrombolysis(P<0.001),and fibrinogen were reduced compared to those before thrombolysis(P<0.001).A total of 35 patients(17.77%)occured comorbidities during treatment.One year after treatment,196 patients(99.49%)with PVT survived,of which thrombus essentially disappeared in 141(71.94%),thrombus stabilized(or decreased)in 42(21.43%),and thrombus increased in 13(6.63%).Conclusion percutaneous liver puncture for local management of PVT is effective and reliable in the short-term and requires standardized management of the entire process.
7. Central mechanism of curcumin on the paraventricular hypothalamic nucleus of high salt induced hypertension rats
Tingting MENG ; Yifan GAO ; Qinglan ZHANG ; Tingting MENG ; Hongli GAO ; Xiaojing YU
Chinese Journal of Clinical Pharmacology and Therapeutics 2023;28(12):1357-1364
AIM: To assess the effect of curcumin in hypothalamic paraventricular nucleus (PVN) and mean arterial pressure so as to explore the central mechanism of hypertension. METHODS: Sixty Sprague-Dawley rats which body weights between 170 and 190 grams fed with a normal salt (0.3% NaCl) or a high salt (8% NaCl) diet for 6 weeks. Meanwhile half of each team received curcumin administration or vehicle by intragastric administration. Mean Arterial pressure was measured noninvasively via tail-cuff instrument and their recording system. The PVN tissue samPles were collected and stored at −80 °C for later analyses. We performed the following experimental procedures: Western blot analysis, immunofluorescence, immunofluorescence and statistical analysis. RESULTS:The average arterial blood Pressure of rats in the high-salt diet group was significantly reduced after 6 weeks of curcumin intervention. The levels of NOX2, NOX4, TLR4, MyD88, IL-6, IL-1β, MCP-1 and ROS in the long-term high-salt diet grouP were significantly higher after curcumin intervention. CONCLUSION:Curcumin can improve blood pressure in hypertensive rats induced by long-term high salt, the mechanism may be related to the imProvement of oxidative stress and inflammatory cytokines in the paraventricular nucleus of the hypothalamus.
8.A study on the alterations of negative functional connectivity and its diagnostic value in schizophrenia
Shuxian YANG ; Yingchao SONG ; Yifan LI ; Yayuan CHEN ; Wen QIN ; Meng LIANG
Chinese Journal of Nervous and Mental Diseases 2023;49(12):727-733
Objective To assess the alterations of negative functional connectivity(FC),its relationship with clinical symptoms,and its potential value in schizophrenia(SZ).Methods Resting-state functional magnetic resonance imaging(rs-fMRI)data were acquired from patients with SZ and healthy controls(HC).For each participant,the whole brain image was first divided into 272 regions and then the FC between each pair of these regions was calculated using Pearson's correlation coefficient.Group-level negative FCs were identified using permutation test for each group.Each of the identified negative FCs was then compared between patients and controls to identify the altered negative FCs.Then,Spearman rank correlation was adopted to examine the relationship between the altered negative FCs and clinical variables.Finally,to evaluate the diagnostic value of negative FC in SZ,a multivariate pattern analysis(MVPA)was performed to distinguish between SZ and HC based on negative FCs.Results Ninety-one patients with SZ and 91 HC were included in this study,and 207 negative FCs in total were identified.Among the identified 207 negative FCs,12(constituting 5.80%of the total 207 negative FCs)were significantly altered in SZ compared with HC(Bonferroni correction,P<0.05),of which 11 were significantly decreased(i.e.,closer to 0)in SZ.The correlation analyses identified 2 significant associations-one was between a negative FC and the total score of the psychotic symptoms rating scales-auditory hallucinations(r=-0.24,P=0.02)and the other was between a negative FC and the weighted total score of the scale for the assessment of thought,language,and communication(r=0.26,P=0.01).Furthermore,the model for distinguishing between SZ and HC based on negative FCs achieved a classification accuracy of 72.6%that was significantly higher than chance-level accuracy(permutation test,P<0.001).Conclusion Negative FCs are altered in patients with SZ.Given that negative FCs are associated with clinical symptoms,thus they may serve as an imaging biomarker for assisting the diagnosis of SZ.
9.Research progress on histone methylation modification in aging cardiovascular disease
Di MENG ; Jing ZHANG ; Ping ZENG ; Li LIU ; Jingyi WU ; Yifan HUANG ; Jian YANG
Journal of Clinical Medicine in Practice 2023;27(23):129-134
Changes in cardiac structure and function such as myocardial aging,valve alterations,alterations in the cardiac conduction system and vascular aging are crucial for studying therapeutic methods for age-related cardiovascular diseases.Histone methylation modification is involved in the regulation of gene expression and closely related to the occurrence and development of age-related car-diovascular diseases.This paper provided a comprehensive review on the role of histone methylation modification in cardiac structural and functional changes,providing new theoretical basis for age-relat-ed cardiovascular diseases.
10.Study on Identification of Ginseng Flos and its Confounding Products Based on High-throughput Sequencing Technology
WANG Menghu ; SUN Yifan ; XU Liang ; KANG Tingguo ; ZUO Yafeng ; ZHAI Junjie ; LI Jinyang ; MENG Xiangsong ; TANG Jian ; WANG Wenjian
Chinese Journal of Modern Applied Pharmacy 2023;40(14):1950-1956
OBJECTIVE To identify Ginseng Flos and their confounds by using the high-throughput sequencing technology, and to verify the accuracy of high-throughput sequencing technology in species identification by using ITS2 sequencing technology. METHODS High-throughput sequencing was performed on the amplified products of Ginseng Flos adulterated samples, use cutadapt, PEAR, PRINSEQ, Usearch, RDP classifier, SINTAX software to obtain operational taxonomic unit(OUT) sequences, remove fungi, unclassified and other non-green plant sequences. To avoid false positives, delete OTU sequences with a sequence number <100 or base numbers <200 bp. The ITS2 amplification products of Ginseng Flos, Quinquefolii Flos, and Notoginseng Flos were sequenced. To verify the accuracy of high-throughput sequencing technology for species identification, MEGA 11.0 was used to construct neighbor joining system cluster tree, genetic distance, interspecific information loci and Blast analysis of ITS2 and OTU base sequences of Ginseng Flos, Quinquefolii Flos, and Notoginseng Flos. RESULTS A total of 54 653 valid sequences were obtained by high-throughput sequencing, the serial numbers of Ginseng Flos, Quinquefolii Flos, and Notoginseng Flos were OTU1, OTU2, OTU3, respectively, and the corresponding effective sequences were 31 325, 857 and 442, respectively. By performing a Blast search of ITS2 and OTU base sequences of each species, each species was supported. The genetic distance between Ginseng Flos and Quinquefolii Flos and Notoginseng Flos was 0.010 and 0.033, respectively. Ginseng Flos and Quinquefolii Flos, Notoginseng Flos had 2 and 7 information sites, respectively. The neighbor join system cluster tree showed that the species were clustered independently into one branch, with Ginseng Flos, and Quinquefolii Flos clustered as a large branch and juxtaposed with Notoginseng Flos. Ginseng Flos was the same as Quinquefolii Flos secondary structure, but with Notoginseng Flos there were three different positions but there were A, B and C differences between arm Ⅳ and arm Ⅰ of Notoginseng Flos. CONCLUSION The high-throughput sequencing technology can accurately identify Ginseng Flos, Quinquefolii Flos and Notoginseng Flos, and has a strong ability to identify adulterated samples, which provides a certain idea for the identification of commercial Ginseng Flos.


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