Standardization of electronic medical records data in rehabilitation
TIAN Yifan
XUN Fang
YE Haiyan
LIU Ye
ZHANG Yingxin
YANG Yaru
WANG Zhongyan
ZHANG Meng
LIU Xiaoxie
YANG Yanyan
ZENG Bin
ZHOU Mouwang
XIE Yuxiao
XU Guangxu
ZHENG Jiejiao
ZHANG Mingsheng
YE Xiangming
HUANG Fubiao
HUANG Qiuchen
WANG Yiji
CHEN Di
QIU Zhuoying
Abstract：Objective To 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.
Methods Based 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 Or-ganization 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 Medi-cal Records,Basic Data Set of Electronic Medical Records,and Specifications for Sharing Documents of Elec-tronic Medical Records,the study constructed and organized the data structure,content,and data standards of re-habilitation electronic medical records.
Results The 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 charac-teristics,emphasizing rehabilitation treatment,into clinical information.By fully applying the WHO-FICs refer-ence classifications,rehabilitation electronic medical records could establish a standardized framework,diagnos-tic criteria,functional description tools,coding tools and terminology index tools for the coding,indexing,func-tional 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 report-ing guidance for rehabilitation electronic medical records.
Conclusion The standardization of rehabilitation electronic medical records is significant for improving the quality of re-habilitation medical services and promoting the rehabilitation process of patients.The development of rehabilita-tion electronic medical records must be based on the national and international standards.Under the general elec-tronic 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 informa-tion.
Keywords：rehabilitationelectronic medical recordsdata standards
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( 33-44 )