Structure,content and data standardization of inpatient rehabilitation medical record summary sheet
YE Haiyan
QIN Qing
LIU Ye
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
Abstract：Objective To 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 re-cord summary sheet,improve data reporting quality,and provide accurate data support for medical insurance pay-ment,hospital performance evaluation,and rehabilitation discipline evaluation.
Methods Based 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,In-ternational Classification of Diseases (ICD-10/ICD-11,ICD-9-CM-3),International Classification of Function-ing,Disability and Health (ICF),and International Classification of Health Interventions (ICHI Beta-3),for dis-ease diagnosis,functional description and assessment,and rehabilitation intervention,forming a standardized ter-minology system and coding methods.
Results The 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.
Conclusion The inpatient rehabilitation medical record summary sheet is a summary of the relevant content of the reha-bilitation 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 accura-cy of inpatient diagnosis of diseases and functions.Based on ICD-11 and ICF,relevant functional assessment re-sult data would be added,and ICHI Beta-3/ICD-9-CM-3 should be used to code rehabilitation interventions.Im-proving 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 analy-sis and application of inpatient rehabilitation medical record summary sheet.
Keywords：inpatient medical record summary sheetdata 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( 55-66 )