Structured Medical Records in Rehabilitation Medicine:Ⅰ. Admission Record/Note
National Center for Healthcare Quality Management in Rehabilitation Medicine Expert Commission
National Center for Healthcare Quality Management in Rehabilitation Medicine Office
National Brain Injury Evaluation and Quality Control Center
Abstract：0 Introduction
In order to improve the standardization of medical record writing in the field of rehabilitation medicine nationwide, enhance the accuracy of data collection, facilitate medical data quality control, achieve homogenization and refinement of rehabilitation quality control, improve the quality of medical records, and implement the comprehensive action to improve medical quality, the Office of the National Center for Quality Control of Rehabilitation Medicine has followed the electronic medical record writing standards. Considering the professional specificity of rehabilitation medicine, it drafted the first version of the structured medical records for admission in the department of rehabilitation medicine in 2019. After multiple revisions through expert committee consultations, national rehabilitation quality control meetings, and collective meetings of the expert committee, it finally formed the Admission Record (Hospitalization Record) for the Department of Rehabilitation Medicine (2023 Edition) under the guidance of the Medical Management Division of the National Health Commission's Medical Administration Department.
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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：3( 67-69 )