《中国康复理论与实践》

《中国康复理论与实践》 ›› 2025, Vol. 31 ›› Issue (1): 55-66.doi: 10.3969/j.issn.1006-9771.2025.01.005

• 专题 康复病历与病历数据研究 • 上一篇    下一篇

康复住院病案首页结构、内容和数据标准化研究

叶海燕1a,2, 秦晴1b,2, 刘叶1a,2, 田益凡1a,2, 张赢心1a,2, 杨亚茹2,3,4, 王忠彦2,3, 张萌2,5, 刘小燮2,6,7,8, 杨延砚2,6,7,8, 曾斌2,9, 周谋望6,7,8, 谢欲晓10, 许光旭11,12, 郑洁皎13, 张鸣生9,14, 叶祥明15,16, 黄富表17a,18, 黄秋晨17b,18,19, 王一吉17c,18, 陈迪1a,2(), 邱卓英2,3()   

  1. 1.中国康复科学所，a. 康复信息研究部；b. 综合办公室，北京市 100068
    2.世界卫生组织国际分类家族中国合作中心，北京市 100068
    3.康复大学社会发展学院/国际康复政策和ICF研究中心，山东青岛市 266113
    4.华东师范大学体育与健康学院，上海市 200241
    5.北京协和医院，北京市 100730
    6.北京大学第三医院，北京市 100191
    7.北京市康复医疗质量控制和改进中心，北京市 100191
    8.国家康复医学专业医疗质量控制中心， 北京市 100191
    9.南方医科大学附属广东省人民医院（广东省医学科学院）康复医学科，广东广州市 510080
    10.中日友好医院康复医学科，北京市 100029
    11.南京医科大学第一附属医院，江苏南京市 210029
    12.南京医科大学康复医学院，江苏南京市 210029
    13.复旦大学附属华东医院，上海市 200040
    14.高州市人民医院康复医学与健康管理中心，广东茂名市 525200
    15.浙江省人民医院/杭州医学院附属人民医院康复医学科，浙江杭州市 310014
    16.浙江省康复与运动医学研究所，浙江杭州市 310014
    17.中国康复研究中心北京博爱医院，a. 作业疗法科；b. 物理疗法科；c. 脊髓损伤康复科，北京市 100068
    18.首都医科大学康复医学院，北京市 100068
    19.西藏自治区残疾人康复（托养）服务中心，西藏拉萨市 850000
  • 收稿日期:2024-12-25 出版日期:2025-01-25 发布日期:2025-01-22
  • 通讯作者: 陈迪(1982-)，男，汉族，北京市人，博士，副研究员，世界卫生组织国际分类家族中国合作中心成员，主要研究方向：ICF、残疾研究、康复科学、康复大数据、康复信息，E-mail： chendi@crrc.com.cn；邱卓英(1962-)，男，汉族，湖北武汉市人，博士，研究员、教授、世界卫生组织国际分类家族中国合作中心联席主任，主要研究方向：ICF、康复心理学、残疾与康复政策、康复科学、康复信息与康复数据科学，E-mail： qiutiger@hotmail.com
  • 作者简介:叶海燕(1997-)，女，汉族，江西赣州市人，硕士，研究实习员，主要研究方向：康复信息。
  • 基金资助:
    1.中国康复科学所中央级公益性科研院所基本科研业务费项目(2022CZ-1);2.中国残联课题(24&BZA001);3.山东省重点研发计划(软科学)(2023RZA01011);3.山东省重点研发计划(软科学)(2023RZB01013);4.国家卫生健康委医院管理研究所医疗质量(循证)管理研究项目(YLZLXZ24G032);5.中央高水平医院临床科研业务费(2022-PUMCH-A-223)

Structure, content and data standardization of inpatient rehabilitation medical record summary sheet

YE Haiyan1a,2, QIN Qing1b,2, LIU Ye1a,2, TIAN Yifan1a,2, ZHANG Yingxin1a,2, YANG Yaru2,3,4, WANG Zhongyan2,3, ZHANG Meng2,5, LIU Xiaoxie2,6,7,8, YANG Yanyan2,6,7,8, ZENG Bin2,9, ZHOU Mouwang6,7,8, XIE Yuxiao10, XU Guangxu11,12, ZHENG Jiejiao13, ZHANG Mingsheng9,14, YE Xiangming15,16, HUANG Fubiao17a,18, HUANG Qiuchen17b,18,19, WANG Yiji17c,18, CHEN Di1a,2(), QIU Zhuoying2,3()   

  1. 1a. Department of Rehabilitation Information Research; b. Department of General Office, China Rehabilitation Science Institute, Beijing 100068, China
    2. WHO-FIC Collaborating Center in China, Beijing 100068, China
    3. School of Social Development/International Center for Rehabilitation Policy and ICF Research, University of Health and Rehabilitation Sciences, Qingdao, Shandong 266113, China
    4. College of Physical Education and Health, East China Normal University, Shanghai 200241, China
    5. Peking Union Medical College Hospital, Beijing 100730, China
    6. Peking University Third Hospital, Beijing 100191, China
    7. Beijing Municipal Center of Healthcare Quality Control and Improvement in Rehabilitation Medicine, Beijing 100191, China
    8. National Center for Healthcare Quality Management in Rehabilitation Medicine, Beijing 100191, China
    9. Department of Rehabilitation Medicine,Guangdong Provincial People's Hospital of Southern Medical University (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong 510080, China
    10. Department of Rehabilitation Medicine, China-Japan Friendship hospital, Beijing 100029, China
    11. The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
    12. School of Rehabilitation Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, China
    13. Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
    14. Rehabilitation Medicine and Health Management Center, Gaozhou People's Hospital, Maoming, Guangdong 525200, China
    15. Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital/People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
    16. Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Hangzhou, Zhejiang 310014, China
    17a. Department of Occupational Therapy; b. Department of Physiotherapy; c. Department of Spinal Cord Injury Rehabilitation, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing 100068, China
    18. Capital Medical University School of Rehabilitation Medicine, Beijing 100068, China
    19. Xizang Autonomous Region Rehabilitation (Care) Center for Persons with Disabilities, Lhasa, Xizang 850000, China
  • Received:2024-12-25 Published:2025-01-25 Online:2025-01-22
  • Contact: CHEN Di, E-mail: chendi@crrc.com.cn; QIU Zhuoying, E-mail: qiutiger@hotmail.com
  • Supported by:
    The Fundamental Research Funds for Central Public Welfare Research Institutes, conducted by China Rehabilitation Science Institute(2022CZ-1);Key Project Funded by China Disabled Persons' Federation(24&BZA001);Key R&D Program (Soft Science Project) of Shandong Province(2023RZA01011);Key R&D Program (Soft Science Project) of Shandong Province(2023RZB01013);Medical Quality (Evidence-Based) Management research project of Hospital Management Research Institute, National Health Commission(YLZLXZ24G032);Central High Level Hospital Clinical Research Business Expenses(2022-PUMCH-A-223)

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摘要：

目的 探索康复住院病案首页数据标准化，涉及康复住院病案首页的结构、内容和数据标准，旨在提高康复住院病案首页数据标准化水平，提升数据填报质量，为医保支付、医院绩效考核、康复学科评价等工作提供准确的数据支持。

方法 基于国家卫生健康委《病历书写基本规范》《电子病历共享文档规范》《住院病案首页数据质量管理与控制指标(2016版)》相关规范，分析康复住院病案首页的结构和内容。系统运用世界卫生组织国际分类家族(WHO-FICs)参考分类《国际疾病分类》(ICD-10/ICD-11, ICD-9-CM-3)、《国际功能、残疾和健康分类》(ICF)和《国际健康干预分类》(ICHI Beta-3)进行疾病诊断、功能描述和评定以及康复干预，形成规范化的术语体系和编码方法。

结果 康复住院病案首页涵盖住院患者信息、住院信息、诊疗信息和费用信息四大板块。ICD-10/ICD-11是康复住院病案首页中的入院诊断和出院疾病诊断的标准和编码工具。ICD-11推荐的3大功能评定工具WHODAS 2.0 36项版本、简明示范残疾调查、通用功能领域以及ICF可用于康复功能评定和评定结果的编码。ICHI Beta-3和ICD-9-CM-3可用于病案首页中的手术和操作编码，也可用于康复干预项目的编码。

结论 康复住院病案首页是对康复病历相关内容的总结，也是康复住院数据上报的工具，需要根据康复医疗的特点进行细化和优化，并且补充必要的数据。应该全面推动ICD-11/ICD-10、ICF和ICHI Beta-3/ICD-9-CM-3分类标准的应用，从而提升住院患者疾病和功能诊断数据的准确性。基于ICD-11和ICF补充相关的功能评估结果数据，运用ICHI Beta-3/ICD-9-CM-3对康复干预进行编码。提升康复病历和康复住院病案首页质量，是康复医疗质量控制的重要环节，也为基于康复住院病案首页的数据分析与应用奠定了循证数据基础。

关键词: 住院病案首页, 数据标准化, 国际疾病分类, 国际功能、残疾和健康分类, 国际健康干预分类

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 record summary sheet, improve data reporting quality, and provide accurate data support for medical insurance payment, 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, International Classification of Diseases (ICD-10/ICD-11, ICD-9-CM-3), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), for disease diagnosis, functional description and assessment, and rehabilitation intervention, forming a standardized terminology 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 rehabilitation 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 accuracy of inpatient diagnosis of diseases and functions. Based on ICD-11 and ICF, relevant functional assessment result data would be added, and ICHI Beta-3/ICD-9-CM-3 should be used to code rehabilitation interventions. Improving 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 analysis and application of inpatient rehabilitation medical record summary sheet.

Key words: inpatient medical record summary sheet, data standardization, International Classification of Diseases, International Classification of Functioning, Disability and Health, International Classification of Health Interventions

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