Standardization of outpatient medical record in rehabilitation setting

LIU Ye; QIN Qing; YE Haiyan; TIAN Yifan; 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

doi:10.3969/j.issn.1006-9771.2025.01.004

Abstract：Objective To analyze the data structure and standards of rehabilitation outpatient medical records,to provide data sup-port for improving the quality of rehabilitation outpatient care and developing medical insurance payment poli-cies. Methods Based 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),refer-ence 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 stan-dards were discussed. Results This study constructed a data framework for rehabilitation outpatient medical records,including four main com-ponents:patient basic information,visit process information,diagnosis and treatment information,and cost infor-mation.Three major reference classifications of WHO-FICs,International Classification of Diseases,Internation-al 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 re-porting,and level of quality control in rehabilitation. Conclusion The structuring and standardization of rehabilitation outpatient medical records are the foundation for shar-ing of rehabilitation data.The using of the three major classifications of WHO-FICs is valuable for the terminolo-gy and coding of disease diagnosis,functional description and assessment,and intervention in rehabilitation out-patient 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.