康复病历的内容结构与数据标准研究

doi:10.3969/j.issn.1006-9771.2025.01.002

Chinese Journal of Rehabilitation Theory and Practice ›› 2025, Vol. 31 ›› Issue (1): 21-32.doi: 10.3969/j.issn.1006-9771.2025.01.002

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Structure, content and data standardization of rehabilitation medical records

YANG Yaru¹^,²^,³, QIU Zhuoying¹^,²(), CHEN Di²^,⁴(), WANG Zhongyan¹^,², ZHANG Meng²^,⁵, WU Shiyong⁶, ZHANG Yaoguang⁶, LIU Xiaoxie²^,⁷^,⁸^,⁹, YANG Yanyan²^,⁷^,⁸^,⁹, ZENG Bin²^,¹⁰, ZHOU Mouwang⁷^,⁸^,⁹, XIE Yuxiao¹¹, XU Guangxu¹²^,¹³, ZHENG Jiejiao¹⁴, ZHANG Mingsheng¹⁰^,¹⁵, YE Xiangming¹⁶^,¹⁷, YANG Jian²^,³, AN Na¹⁸, DONG Yuanjun¹, XIN Xiaojia¹^,¹⁹, REN Xiangxia¹^,¹⁸^,²⁰, LIU Ye²^,⁴, TIAN Yifan²^,⁴

1. School of Social Development/International Center for Rehabilitation Policy and ICF Research, University of Health and Rehabilitation Sciences, Qingdao, Shandong 266113, China
2. WHO-FIC Collaborating Center in China, Beijing 100068, China
3. College of Physical Education and Health, East China Normal University, Shanghai 200241, China
4. Rehabilitation Information Research Department, China Rehabilitation Science Institute, Beijing 100068, China
5. Peking Union Medical College Hospital, Beijing 100730, China
6. Center for Health Statistics and Information, National Health Commission of the People's Republic of China, Beijing 100044, China
7. Department of Rehabilitation, Peking University Third Hospital, Beijing 100191, China
8. Beijing Municipal Center of Healthcare Quality Control and Improvement in Rehabilitation Medicine, Beijing 100191, China
9. National Center for Healthcare Quality Management in Rehabilitation Medicine, Beijing 100191, China
10. Department of Rehabilitation Medicine, Guangdong Provincial People's Hospital of Southern Medical University (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong 510080, China
11. Department of Rehabilitation Medicine, China-Japan Friendship Hospital, Beijing 100029, China
12. The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
13. School of Rehabilitation Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, China
14. Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
15. Rehabilitaition Medicine and Health Management Center, Gaozhou People's Hospital, Maoming, Guangdong 525200, China
16. Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital/People's Hospital of Hangzhou Medical College, Hanghzou, Zhejiang 314408, China
17. Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Hangzhou, Zhejiang 310014, China
18. School of Public Education, University of Health and Rehabilitation Sciences, Qingdao, Shandong 266113, China
19. Shandong Province Population Health and Public Policy Soft Science Base, University of Health and Rehabilitation Sciences, Qingdao, Shandong 266113, China
20. Qingdao Health Technology and Industrial Policy Research Base, Qingdao, Shandong 266113, China

Received:2024-12-23 Published:2025-01-25 Online:2025-01-22
Contact: QIU Zhuoying, E-mail: qiutiger@hotmail.com; CHEN Di, E-mail: chendi@crrc.com.cn
Supported by:
The Fundamental Research Funds for Central Public Welfare Research Institutes, conducted by China Rehabilitation Science Institute(2022CZ-1);Key Project Funded China Disabled Persons' Federation(24&BZA001);Shandong Key Research and Development Plan (Soft Science) Project(2023RZA01011);Shandong Key Research and Development Plan (Soft Science) Project(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 elucidate the critical role of rehabilitation medical records (including electronic records) in rehabilitation medicine's clinical practice and management, comprehensively analyzed the structure, core content and data standards of rehabilitation medical records, to develop a standardized medical record data architecture and core dataset suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evaluation and payment.

Methods Based on the regulatory documents Basic Specifications for Medical Record Writing and Basic Specifications for Electronic Medical Records (Trial) issued by National Health Commission of China, and referencing the World Health Organization (WHO) Family of International Classifications (WHO-FICs) classifications, International Classification of Diseases (ICD-10/ICD-11), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), this study constructed the data architecture, core content and data standards for rehabilitation medical records. Furthermore, it explored the application of rehabilitation record summary sheets (home page) data in rehabilitation medical statistics and payment methods, including Diagnosis-related Groups (DRG), Diagnosis-Intervention Packet (DIP) and Case Mix Index.

Results This study proposed a systematic standard framework for rehabilitation medical records, covering key components such as patient demographics, rehabilitation diagnosis, functional assessment, rehabilitation treatment prescriptions, progress evaluations and discharge summaries. The research analyzed the systematic application methods and data standards of ICD-10/ICD-11, ICF and ICHI Beta-3 in the fields of medical record terminology, coding and assessment. Constructing a standardized data structure and data standards for rehabilitation medical records can significantly improve the quality of data reporting based on the medical record summary sheet, thereby enhancing the quality control of rehabilitation services, effectively supporting the optimization of rehabilitation medical insurance payment mechanisms, and contributing to the establishment of rehabilitation medical performance evaluation and payment based on DRG and DIP.

Conclusion Structured rehabilitation records and data standardization are crucial tools for quality control in rehabilitation. Systematically applying the three reference classifications of the WHO-FICs, and aligning with national medical record and electronic health record specifications, facilitate the development of a standardized rehabilitation record architecture and core dataset. Standardizing rehabilitation care pathways based on the ICF methodology, and developing ICF- and ICD-11-based rehabilitation assessment tools, auxiliary diagnostic and therapeutic systems, and supporting terminology and coding systems, can effectively enhance the quality of rehabilitation records and enable interoperability and sharing of rehabilitation data with other medical data, ultimately improving the quality and safety of rehabilitation services.

Key words: rehabilitation medical records, medical record data standardization, International Classification of Diseases, International Classification of Functioning, Disability and Health, International Classification of Health Interventions

CLC Number:

R197.3

YANG Yaru, QIU Zhuoying, CHEN Di, WANG Zhongyan, ZHANG Meng, WU Shiyong, ZHANG Yaoguang, LIU Xiaoxie, YANG Yanyan, ZENG Bin, ZHOU Mouwang, XIE Yuxiao, XU Guangxu, ZHENG Jiejiao, ZHANG Mingsheng, YE Xiangming, YANG Jian, AN Na, DONG Yuanjun, XIN Xiaojia, REN Xiangxia, LIU Ye, TIAN Yifan. Structure, content and data standardization of rehabilitation medical records[J]. Chinese Journal of Rehabilitation Theory and Practice, 2025, 31(1): 21-32.

Figures/Tables 4

Table 1

Structure, content and datasets of rehabilitation medical records"

结构	内容	数据字段示例	数据字符集/编码	HIS实现方式
患者基本信息	姓名、性别、出生日期、年龄、身份证号、联系方式等住院号/门诊号医保类型等	Patient Name (字符串) Gender (代码或枚举) Birth Date (日期) ID Number (字符串)	国家或医院内部标准数据字典(姓名、性别等) 住院号/门诊号与HIS对接	全院统一来源于病人主索引(Master Patient Index, MPI) 实现一次录入，多处调用
病案首页	主要诊断(ICD-10/ICD-11) 其他诊断功能评估摘要(ADL等) 住院/门诊时间、手术操作费用信息离院方式	Main Diagnosis Code (ICD-10/ICD-11) Operation Code (ICD-9-CM-3/ICHI Beta-3) Functional Score (数字)	诊断编码使用ICD-10/ICD-11 手术操作编码使用ICD-9-CM-3/ICHI Beta-3 评估工具：ADL，WHODAS 2.0、通用功能领域以及简明示范残疾调查等	病案首页有规范格式要求需及时报送为DRG/DIP/Case Mix分析提供信息
现病史与评估	现病史、既往史、过敏史康复评估(如运动功能、语言吞咽、日常生活活动评定等)	Present Illness (文本) Past History (文本) Assessment Tools (数组)	文字描述+评估量表：如ADL、WHODAS 2.0等可引用ICF核心分类	使用ASIA、ADL等评估工具，可以运用ICF对评估结果进行编码并且将评估结果转换成ICF限定值建议使用ICD-11推荐的三个标准化评估工具，其中WHODAS 2.0是主要参照的评估工具 HIS可对评估工具的结果进行可视化和运用ICF进行编码，以便于功能相关数据分析
康复诊断与目标	疾病与功能诊断：运用ICD-11和ICF进行疾病和功能诊断并且进行编码确定康复短期/长期目标	Disease Function Diagnosis (字符串+ICD-11编码/ICD-10国家临床版编码+ICF编码) Short Term Goal (文本) Long Term Goal (文本)	康复功能诊断可结合ICF大类(b、s、d、e) 目标尽量量化(如关节活动度、肌力等级等)	与临床诊断相互补充；明确康复方向和阶段性目标
康复处方与治疗记录	康复干预处方：PT、OT、ST、传统中医康复等处方参数(频次、时长等) 实施情况与不良事件	Rehab Prescription (数组) Treatment Record (数组)	干预操作编码可用ICD-9-CM-3/ICHI Beta-3 记录治疗开始/结束时间、治疗师签名	作为康复病历区别于一般临床病历的关键，需多学科联署
阶段小结/病程记录	阶段性评估与效果总结康复治疗进展和调整方案是否达成阶段目标	Progress Note Date (日期) Progress Evaluation(文本) Adjusted Plan (文本)	每周或每阶段更新功能指标常见量表重复测量(ADL、WHODAS 2.0等)制作成动态变化曲线	使用电子化系统有自动提醒和数据可视化技术，追踪患者的康复进程
出院小结及随访	出院时功能状态、主要康复成效出院医嘱、家庭康复指导随访计划、复诊时间	Discharge Summary (文本) Home Exercise Plan (文本) Follow Up Plan (日期/文本)	与病案首页离院信息一致，补充详细康复建议家庭康复指导可结合文字+示意图	强调康复的持续性，注重出院后定期评估和干预

Table 1

Table 2

Relationship between summary sheets of rehabilitation medical records and the contents of rehabilitation medical records"

康复病案首页信息	康复病历对应模块	说明
患者基本信息 (姓名、性别、年龄、身份证号、联系方式等)	门诊/住院康复病历中“患者基本资料” 病案首页与MPI的信息同步	病案首页上“患者基本信息”字段，是康复病历最基础、最先录入的内容在康复病历中通常放于“病历首页”或“基础信息”模块，HIS/电子病历系统会自动调取并保持一致确保后续所有康复诊疗活动都能准确匹配到该患者身份
主要诊断/其他诊断(ICD-10或ICD-11编码)	康复病历中“康复诊断”或“住院诊断记录” 与病程记录、康复评估结果互相印证	病案首页上的主要诊断和其他诊断基于ICD-10国家临床版或ICD-11进行编码，是对患者临床情况和功能障碍情况的高度概括康复病历中会有更详细的诊断依据、临床症状和评估量表结果支撑，并可体现诊断变动或诊断演进过程(如阶段性诊断变更)
功能障碍或功能评估摘要 (Barthel指数、ADL、WHODAS 2.0等量表)	康复评定记录或评估表康复病程中阶段性评估结果(如初评、复评、出院评估)	病案首页往往只填写功能评估的核心指标或总分，如Barthel指数总分、WHODAS 2.0总分在康复病历中则会有具体量表条目、评分细节和对功能障碍的定性及定量分析；并记录反复评定的过程，以对比康复进度可结合ICF核心分类进行系统化的功能状况记录
手术/操作编码 (如ICD-9-CM-3、ICHI Beta-3等)	手术或介入操作记录康复治疗处方与执行记录	病案首页仅列出主要或有创的手术操作(如矫形手术、重要介入操作) 康复病历会详细记录多学科干预(PT、OT、ST、心理治疗等)，可能在首页中只做摘要或不体现具体编码，详细操作则在康复病历中的处方与执行单内呈现如需要统计与费用核对，首页可与康复治疗处方(执行单)相互校对
门诊/住院费用信息 (总费用、医保支付、自费金额等)	费用清单或财务结算信息康复病历一般不直接存储费用细项，但可能附带主要项目清单	病案首页对费用信息多为汇总数据，如总费用、康复费用占比、医保支付金额等康复病历中主要关注诊疗过程和医疗操作，费用清单通常在HIS或财务系统管理，不会在康复病历中详细呈现。但在某些医院信息系统中，会在康复处方单关联费用
诊疗过程概要 (入院/门诊就诊情况、主要治疗、出院情况)	康复病程记录/阶段小结/出院小结康复护理记录/康复治疗记录	病案首页常用简练的文字描述或关键数据来概述诊疗过程康复病历会包含更详细、连续性的病程记录，如：每日或每周的康复评定与效果干预方案的调整、患者主观感受 PT、OT、ST等多学科信息的完整记录
离院方式 (治愈、好转、未愈、死亡、转院等)	康复出院小结出院医嘱与随访计划	病案首页填写“离院方式”是国家统一要求，用以做质量控制与统计康复出院小结中会记录患者出院时功能状态、主要康复成效、是否需要继续门诊或社区康复康复病历对康复目标达成情况、后续康复计划、预后评估等内容做了详细阐述

Table 2

Table 3

Systematic application of three reference classifications of WHO-FIC in rehabilitation medical records"

应用场景/字段	ICD-11/ ICD-10(国家临床版)	ICF	ICHI Beta-3/ICD-9-CM-3	说明/备注
编码：主诊断、其他诊断	ICD-11或ICD-10(国家临床版)用于疾病诊断的分类与编码病案首页中一般必须填写主要诊断(主诉疾病或功能障碍)，如“脑卒中后偏瘫(ICD-10：I69.3)” 其他诊断(并发症、合并症)也按ICD编码填写卫生健康委和国家医保局推荐使用ICD-11 ICD-10可以通过工具转换成ICD-11 病案首页上传国家医院管理局的临床医疗数据库	ICF不直接替代疾病编码，更多地用于功能状态、活动受限和参与限制的分类在病案首页可附加“功能障碍诊断”字段引用ICF编码以补充对功能状态的描述(如ICF的b7运动功能、d4 活动与参与等)	ICHI Beta-3(或ICD-9-CM-3)主要是对手术、操作、检查等进行编码可以用ICHI Beta-3/ICD-9-CM-3涉及“操作”或“干预”部分进行编码	主诊断与其他诊断是病案首页的核心数据 ICD-10(国家临床版)是目前国内通用编码体系，ICD-11也是推广应用的新分类标准 ICF编码可作为补充信息表征功能障碍性质
术语和词表	ICD-11/ICD-10作为诊断术语的标准词表 ICD-10国家临床版已经成为国家标准 SNOMET-CT系统已经融入中文术语	ICF是功能与残疾的分类分级标准，用于补充医学诊断在功能层面的缺失	ICHI Beta-3/ICD-9-CM-3为干预和手术操作定义了标准术语与编码，如“针灸”“理疗”等	在病案首页中，通常会引用ICD-10(国家临床版)词表来填写诊断名称 ICF术语主要在康复科用于记录功能评估，通常不直接显示在首页上，但可用于病历系统的术语、编码和功能评定等方面 ICHI Beta-3/ICD-9-CM-3多用于操作项词表(手术、康复干预)
功能评估：ICD-11推荐的三个评估工具(WHODAS 2.0、通用功能领域和示范性残疾调查)及ICF评估工具(ICF核心分类)	ICD-11中对功能状况的关注度有所提升，但主要诊断编码仍以疾病为主 WHO推荐的WHODAS 2.0是ICD-11推荐的功能评估工具，用于衡量活动和参与受限程度	ICF评估工具(ICF核心分类)：可针对常见病种(如脑卒中、脊髓损伤)编制核心分类表在病案首页可简要记录功能评估结果，如 Barthel指数、ADL、WHODAS2.0总分或通用功能领域(ICD-11推荐的功能评估)	ICHI Beta-3/ICD-9-CM-3主要是干预操作编码，与功能评估工具关联较少，但可对“评估操作”进行编码(如“功能评定”)	病案首页中常简化功能评估信息：只记录主要量表总分或等级(如Barthel指数或WHODAS 2.0总分) 详细的功能评估在康复病历中描述；首页通常只保留摘要(入院/出院评分)以利于统计分析
门诊/住院干预：多学科干预及ICHI Beta-3(ICD-9-CM-3)编码，康复检查、评估/治疗处方	与疾病或障碍相关的诊断编码还是基于ICD-10/ICD-11 不同康复治疗往往无需另设疾病编码，但可在病案记录中关联ICD-10诊断	ICF强调功能维度，可用于描述康复目标(如提升活动参与度) 不直接提供“干预”编码，但能用作评估干预效果的参照标准	ICHI Beta-3/ICD-9-CM-3 用于康复操作、治疗手段的编码(如“运动疗法”“电刺激”“OT”等)，在病案首页或医嘱系统中可相应列出操作名称及编码有助于费用统计与病例分类管理	门诊和住院干预项目常通过处方或医嘱来呈现，并与ICHI Beta-3/ICD-9-CM-3进行对应编码病案首页通常只展示主要干预项目的名称/编码摘要，便于医保或统计部门的审核和对照
门诊/住院费用信息：项目与收费标准	与ICD-10/ICD-11的关联主要体现在费用结算时对应诊断相关分组(DRG/DIP) 不直接使用ICD 编码来计算费用，但诊断编码是医保分组的依据之一	ICF不直接用于费用结算，其功能分类更多是辅助临床评估和康复方案制定	ICHI Beta-3/ICD-9-CM-3对干预操作的编码可能关联相应的收费项目不同干预操作(如理疗、OT、针灸等)会对应不一样的收费编码	病案首页的费用字段通常只显示总费用、医保支付、自付比例等汇总信息具体收费明细对应医院HIS的项目编码，如理疗1次记账多少等
门诊/住院诊疗过程概要	诊断沿用ICD-10/ICD-11编码；病案首页中的诊疗过程概要多是文字信息，如“入院情况、康复治疗时长”等	ICF的“活动与参与”可指导撰写康复过程概要，描述功能变化量化信息可来自ICF量表或功能评定量表	若诊疗过程中涉及重要手术或介入操作(ICHI Beta-3/ICD-9-CM-3编码项)，病案首页可列出手术名称及操作编码一般的PT、OT等操作在首页通常不逐一列出，只在康复病程中详细记录	病案首页简介要素主要入院情况、诊疗措施概述、出院情况，较少写到具体每一次操作细节重要操作(如手术或高值介入)必须在首页体现编码
离院方式	ICD系列并不直接处理离院方式编码但诊断会影响最终转归判断及医保结算	ICF可辅助判断出院时功能状况及预后，但不涉及离院方式的编码本身	ICHI Beta-3/ICD-9-CM-3 与离院方式关系较小，主要还是记录干预操作过程	离院方式一般采用卫生健康委统一标准(如治愈、好转、自动出院、死亡、转院等)，在首页登记；康复领域也可以用康复结局加以说明可以使用ICD或ICF术语

Table 3

Table 4

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统计方法	概念	基于康复病历首页的数据应用	作用	对标规范
DRG	将住院患者按照疾病诊断、手术操作、年龄、并发症等因素进行分组，每组赋予相应的权重，用于支付和绩效评价	利用住院康复病历首页的主要诊断、手术操作、年龄、住院天数等信息，将康复患者分入不同的DRG，并进行支付和绩效评价	促进康复医疗服务的标准化、规范化；控制医疗费用；进行绩效评价	《国家医疗保障疾病诊断相关分组(CHS-DRG)分组方案 3.0版》；各省市的DRG实施细则
DIP	基于历史数据，确定每个病种的分值，根据分值进行支付	利用住院和门诊康复病历首页的主要诊断、年龄等信息，结合康复评定结果(如Barthel指数变化)，将康复患者分入不同的DIP病种，并进行支付和绩效评价	简化支付流程；激励医疗机构提供适宜的康复服务；控制康复医疗费用	《国家医疗保障按病种分值付费（DIP)技术规范》；《国家医疗保障按病种分值付费(DIP）病种目录库(1.0版)》
Case Mix	描述医院或科室收治患者的疾病严重程度和资源消耗情况的指标体系，用于医院管理、绩效评价和资源配置	利用康复病历首页的患者基本信息、诊断信息、手术操作信息、康复评定信息等，构建康复Case Mix指标体系，例如：患者平均年龄主要诊断构成比平均住院日 Barthel指数(其他功能评分)平均评分及变化	进行康复医疗服务绩效评价；指导康复资源配置；进行康复医疗服务质量管理	暂无统一国家标准，在康复领域有许多此类研究和应用，如美国的Case Mix

Structure, content and data standardization of rehabilitation medical records

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