康复电子病历数据标准化研究

doi:10.3969/j.issn.1006-9771.2025.01.003

Chinese Journal of Rehabilitation Theory and Practice ›› 2025, Vol. 31 ›› Issue (1): 33-44.doi: 10.3969/j.issn.1006-9771.2025.01.003

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Standardization of electronic medical records data in rehabilitation

TIAN Yifan¹^,², XUN Fang¹, YE Haiyan¹^,², LIU Ye¹^,², ZHANG Yingxin¹^,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 Fubiao^17a^,¹⁸, HUANG Qiuchen^17b^,¹⁸^,¹⁹, WANG Yiji^17c^,¹⁸, CHEN Di¹^,²(), QIU Zhuoying²^,³()

1. Department of Rehabilitation Information Research, 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
17. a. 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:2024-11-25 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-10);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)

Abstract

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 Organization 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 Medical Records, Basic Data Set of Electronic Medical Records, and Specifications for Sharing Documents of Electronic Medical Records, the study constructed and organized the data structure, content, and data standards of rehabilitation 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 characteristics, emphasizing rehabilitation treatment, into clinical information. By fully applying the WHO-FICs reference classifications, rehabilitation electronic medical records could establish a standardized framework, diagnostic criteria, functional description tools, coding tools and terminology index tools for the coding, indexing, functional 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 reporting guidance for rehabilitation electronic medical records.

Conclusion The standardization of rehabilitation electronic medical records is significant for improving the quality of rehabilitation medical services and promoting the rehabilitation process of patients. The development of rehabilitation electronic medical records must be based on the national and international standards. Under the general electronic 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 information.

Key words: rehabilitation, electronic medical records, data standards

CLC Number:

R197.3

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. Standardization of electronic medical records data in rehabilitation[J]. Chinese Journal of Rehabilitation Theory and Practice, 2025, 31(1): 33-44.

Figures/Tables 5

Table 1

Structure, content and standards or regulations of rehabilitation electronic medical records"

结构	项目^a	对应标准或规范
基本信息	文档标识信息(H.01)、服务对象标识信息(H.02)、基本人口学信息(H.03)、亲属/联系人信息(H.04)、地址(H.05)通信(H.06)、卫生服务机构(H.08)、卫生服务者(H.09) 事件摘要(H.10)	内容范畴参照WS/T 363 卫生健康信息数据元目录系列标准、WS 445-2014 电子病历基本数据集系列标准等规范文件；数据编码标准参照WS/T 364 卫生健康信息数据元值域代码系列标准、GB/T 2261 个人基本信息分类与代码系列标准、GB/T 6565 职业分类与代码、 GB/T 8561 专业技术职务代码等规范文件
诊断	症状与体征(S.01)、体格检查(S.02)、现病史(S.03)、既往史(S.04)、检查(含病理)(S.05)、医学检验(S.06)、疾病诊断信息(S.07)、评估(S.11)	内容范畴参照WS/T 363 卫生健康信息数据元目录系列标准、WS 445-2014 电子病历基本数据集系列标准等规范文件；数据编码标准参照WS/T 364 卫生健康信息数据元值域代码系列标准、ICD-10或ICD-11等国际分类规范文件
干预	操作记录(S.08)、药物处方(S.09)、治疗计划(S.10)、诊疗过程记录(S.12)、护理(S.14)、健康指导(S.15)、干预结果(S.11.001)、医疗质量(S.11.002)	内容范畴参照WS/T 363 卫生健康信息数据元目录系列标准、WS 445-2014 电子病历基本数据集系列标准等规范文件；数据编码标准参照WS/T 364 卫生健康信息数据元值域代码系列标准、ICD-11、ICHI、ICD-9-CM-3等国际分类规范文件
费用	医保(H.07)、医疗费用(S.13)	内容范畴参照WS/T 363 卫生健康信息数据元目录系列标准、WS 445-2014 电子病历基本数据集系列标准等规范文件；数据编码标准参照WS/T 364 卫生健康信息数据元值域代码系列标准、全国医疗服务项目技术规范(2023年版)^[17]等规范文件

Table 1

Table 2

Table 3

Diagnostic information in rehabilitation electronic medical records (case of spinal cord injury)"

临床数据组类^a	数据元标识符^b	名称	描述	康复电子病历填报举例
S.01主诉(症状/体征)	DE04.01.119.00	主诉	患者向医师描述的对本次疾病相关感受的主要记录	腰部以下感觉减退，双下肢无力
S.01主诉(症状/体征)	DE04.01.116.00	症状编码	个体症状在特定编码体系中的代码	MB40.3^c； FB32.Y & XK9J & XA47J0^c
S.02.010体格检查：功能	DE04.10.088.00	肌力检查结果	受检者肌力检查结果的详细描述	双下肢肌力2级
S.02.010体格检查：功能	DE04.01.026.00	感觉异常情况	对个体感觉异常情况的详细描述	双下肢感觉减退
S.03现病史	DE02.10.071.00	现病史	对患者当前所患疾病情况的详细描述	患者于某日在某某康复中心就诊，行腰椎MRI检查，示L2-L3椎体水平不完全脊髓损伤，接受腰椎后路椎板成形术(03.0900x027)^d，术后双下肢无力麻木稍改善为求进一步康复，于某日于我院门诊就诊，行腰椎MRI复查，示L2-L3椎体水平脊髓损伤较前有所吸收，ASIA分级C级，双下肢感觉减退，肌力3级，拟“脊髓损伤康复”收入我科
S.07诊断	DE05.01.172.00	诊断结果描述	对患者罹患疾病诊断结果的结论性描述	腰椎术后，腰1不完全性脊髓损伤
	DE05.01.024.10	入院诊断西医疾病代码	患者入院时做出的疾病诊断在西医诊断特定编码体系中的编码	NB62.1^c
	DE05.01.056.00	明确诊断检查项目描述	对患者罹患疾病作出诊断所涉及的检查项目描述	日常生活能力评定(93.01009)^d：部分依赖，患者能在部分活动中独立完成，但在如厕、穿衣等方面需要协助肌功能手法测试(93.0400)^d：肌力和肌耐力轻度减退，需要通过特定的肌力训练来提高等速肌力测定(93.0401)^d：膝关节屈肌和伸肌峰力矩低于正常值，建议进行等速肌力训练以改善

Table 3

Table 4

Intervention information in rehabilitation electronic medical records (case of spinal cord injury)"

临床数据组类^a	数据元标识符^b	名称	描述	康复电子病历填报示例
S.08操作	DE06.00.094.00	手术/操作名称	实施手术/操作的名称的详细描述	关节运动训练4组，每天2次；运动训练每天3次；联合物理治疗每天2次；平衡功能训练每天2次；日常生活动作训练每次45 min，每天2次；生物反馈治疗每次45 min，每天1次
	DE06.00.093.00	手术/操作代码	手术/操作的分类代码	93.1400^c 93.1900x001^c 93.3800x001^c 93.3803^c 93.8300x002^c 94.3901^c
	DE06.00.187.00	手术/操作目标部位名称	实施手术/操作的人体部位名称	下肢肌肉、髋关节、膝关节和踝关节
	DE06.00.251.00	手术/操作方法	手术、操作方法的详细描述	关节运动训练：推拿揉搓、不负重屈伸膝、绷腿法、坐位荡腿等运动训练：主动运动和被动运动联合物理治疗：关节活动度锻炼、理疗按摩、肌力锻炼等平衡功能训练：无器械平衡训练、简易设备平衡训练、仪器平衡训练等日常生活动作训练：穿脱衣物，下床、转移、如厕等肌电生物反馈治疗：采集靶肌肉肌电信号放大后转换为视觉、听觉等信号反馈给大脑中枢，帮助患者了解肌肉收缩状态，训练和调节肌肉活动
	DE06.00.250.00	手术/操作次数	手术、操作方法的次数	1(套）
S.10诊疗计划	DE06.00.159.00	治疗方案	根据转诊患者的临床表现、实验室检查结果等为患者制定的治疗方案的详细描述	康复训练和物理治疗，包括肌电生物反馈治疗和运动康复训练
	DE06.00.108.00	随访方式代码	进行医学随访的方式类别在特定编码体系中的编码	1 (门诊)^b
	DE06.00.112.00	随访周期建议代码	患者接受医学随访的建议间隔时长在特定编码体系中的编码	02 (每1个月)^b
S.11评估	DE05.10.033.00	健康状况评估	根据患者疾病临床表现、实验室检查结果等作出的健康问题评估结果的详细描述	神经功能评估、肌力评估、感觉评估、日常生活活动能力评估
	DE05.10.032.00	健康状况描述	个体健康状况的详细描述	神经功能：部分恢复；肌力：双下肢3级；感觉：双下肢部分丧失；日常生活活动能力：部分依赖

Table 4

Table 5

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临床数据组类^a	数据元标识符^b	名称	描述	康复电子病历填报举例
H.08卫生服务机构	DE08.10.013.00	机构名称	机构的组织机构名称	××康复专科医院
	DE08.10.026.00	科室名称	标识个体在医院就诊的科室名称	康复医学科
	DE06.00.175.00	转诊记录	对患者转诊过程的描述	因脊髓损伤康复急性康复期入院××康复中心，出院后转入至××康复专科医院
H.09卫生服务者	DE02.01.039.00	服务者姓名	其他场景或角色中个体在公安管理部门正式登记注册的姓氏和名称；个体在公安管理部门正式登记注册的姓氏和名称	张三
	DE08.30.015.00	人员资质类别名称	职业卫生技术机构的人员拥有的资质证书类别名称	康复医师
	DE02.01.056.00	专业技术职务资格	个体的专业技术资格的名称在特定编码体系中的代码	263(主管技师)^b
	DE02.01.037.00	所学专业代码	个体所学专业在特定编码体系中的代码	320601(康复治疗)^b

临床数据组类^a	数据元标识符^b	名称	描述	康复电子病历填报示例
H.07医保	DE07.00.007.00	医疗费用来源类别代码	患者单次住院期间所发生费用的来源在特定编码体系中的编码	2(城镇居民基本医疗保险)^b
S.13医疗费用	DE07.00.009.00	住院费用分类名称	住院者住院所发生的费用项目名称	康复治疗费：包括MAMBS001^c脊髓损伤ASIA评价×元/次共计×次、FAD1G702^c日常生活能力评定量表测评(ADL)×元/次共计×次、MBBZX003^c持续性被动关节活动范围训练×元/课时共计×课时、MBCZ×003^c日常生活能力训练×元/课时共计×课时、MEDZX003^c肌电生物反馈治疗×元/课时共计×课时
	DE07.00.008.00	住院费用分类代码	住院者住院所发生的收费项目的类别在特定编码体系中的编码	04(康复类费用：住院期间对患者进行康复治疗产生的费用，包括康复评定和治疗)^b
	DE07.00.010.20	康复类费用	患者住院期间对患者进行康复治疗产生的费用，包括康复评定和治疗，计量单位为元	××元^d
	DE07.00.010.00	住院费用(元)	住院者在某次住院期间所有项目总费用，计量单位为人民币元	××元^d
	DE07.00.001.00	个人承担费用(元)	因疾病治疗或健康体检个人承担的费用，计量单位为人民币元	××元^d

Standardization of electronic medical records data in rehabilitation

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