Structure,content and data standardization of rehabilitation medical records
YANG Yaru
QIU Zhuoying
CHEN Di
WANG Zhongyan
ZHANG Meng
WU Shiyong
ZHANG Yaoguang
LIU Xiaoxie
YANG Yanyan
ZENG Bin
ZHOU Mouwang
XIE Yuxiao
XU Guangxu
ZHENG Jiejiao
ZHANG Mingsheng
YE Xiangming
YANG Jian
AN Na
DONG Yuanjun
XIN Xiaojia
REN Xiangxia
LIU Ye
TIAN Yifan
Abstract：Objective To 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 stan-dards of rehabilitation medical records,to develop a standardized medical record data architecture and core datas-et suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evalua-tion and payment.
Methods Based 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,Interna-tional 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 pay-ment methods,including Diagnosis-related Groups (DRG),Diagnosis-Intervention Packet (DIP) and Case Mix Index.
Results This study proposed a systematic standard framework for rehabilitation medical records,covering key compo-nents such as patient demographics,rehabilitation diagnosis,functional assessment,rehabilitation treatment pre-scriptions,progress evaluations and discharge summaries.The research analyzed the systematic application meth-ods and data standards of ICD-10/ICD-11,ICF and ICHI Beta-3 in the fields of medical record terminology,cod-ing and assessment.Constructing a standardized data structure and data standards for rehabilitation medical re-cords 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 perfor-mance evaluation and payment based on DRG and DIP.
Conclusion Structured rehabilitation records and data standardization are crucial tools for quality control in rehabilita-tion.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 rehabilita-tion record architecture and core dataset.Standardizing rehabilitation care pathways based on the ICF methodolo-gy,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 re-cords and enable interoperability and sharing of rehabilitation data with other medical data,ultimately improving the quality and safety of rehabilitation services.
Keywords：rehabilitation medical recordsmedical record data standardizationInternational Classification of DiseasesInternational Classification of FunctioningDisability and HealthInternational Classification of Health Interventions
Publication Date：2025-01-24
Online Publishing Date：2025-08-15(First online date of this platform, not the publication date of the document)
Pages：12( 21-32 )