《中国康复理论与实践》

《中国康复理论与实践》 ›› 2025, Vol. 31 ›› Issue (1): 21-32.doi: 10.3969/j.issn.1006-9771.2025.01.002

• 专题 康复病历与病历数据研究 • 上一篇    下一篇

康复病历的内容结构与数据标准研究

杨亚茹1,2,3, 邱卓英1,2(), 陈迪2,4(), 王忠彦1,2, 张萌2,5, 吴士勇6, 张耀光6, 刘小燮2,7,8,9, 杨延砚2,7,8,9, 曾斌2,10, 周谋望7,8,9, 谢欲晓11, 许光旭12,13, 郑洁皎14, 张鸣生10,15, 叶祥明16,17, 杨剑2,3, 安娜18, 董原君1, 辛晓佳1,19, 任祥霞1,18,20, 刘叶2,4, 田益凡2,4   

  1. 1.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
    2.世界卫生组织国际分类家族中国合作中心，北京市 100068
    3.华东师范大学体育与健康学院，上海市 200241
    4.中国康复科学所康复信息研究部，北京市 100068
    5.北京协和医院，北京市 100730
    6.国家卫生健康委统计信息中心，北京市 100044
    7.北京大学第三医院康复医学科，北京市 100191
    8.北京市康复医疗质量控制和改进中心，北京市 100191
    9.国家康复医学专业医疗质量控制中心， 北京市 100191
    10.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
    11.中日友好医院康复医学科，北京市 100029
    12.南京医科大学第一附属医院，江苏南京市 210029
    13.南京医科大学康复医学院，江苏南京市 210029
    14.复旦大学附属华东医院，上海市 200040
    15.高州市人民医院 康复医学与健康管理中心，广东茂名市 525200
    16.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 314408
    17.浙江省康复与运动医学研究所，浙江杭州市 310014
    18.康复大学公共教学部，山东青岛市 266113
    19.康复大学山东省人口健康公共政策软科学研究基地，山东青岛市 266113
    20.青岛市健康科技与产业政策研究基地，山东青岛市 266113
  • 收稿日期:2024-12-23 出版日期:2025-01-25 发布日期:2025-01-22
  • 通讯作者: 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；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
  • 作者简介:杨亚茹(1997-)，女，汉族，北京市人，博士研究生，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：WHO国际健康分类参考标准、残疾标准与残疾统计、康复心理学、特殊教育、康复科学、健康心理学、锻炼心理学、残疾研究。
  • 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 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. 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)

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摘要：

目的 阐明康复病历(包括电子病历)在康复医学临床实践和管理中的重要作用，解析康复病历的结构、核心内容及数据标准，构建适用于康复医学的标准化病历数据架构和核心数据集，并探讨康复数据在绩效评估和支付结算中的应用。

方法 依据国家卫生健康委员会发布的《病历书写基本规范》和《电子病历基本规范(试行)》，参照世界卫生组织国际分类家族(WHO-FICs)的核心分类《国际疾病分类》(ICD-10/ICD-11)、《国际功能、残疾和健康分类》(ICF)和《国际健康干预分类》(ICHI Beta-3)，构建了康复病历的数据架构、核心内容和数据标准。在此基础上，探讨了康复病案首页数据在疾病诊断相关分组(DRG)、按病种分值付费(DIP)和病例组合指数(Case Mix)等康复医疗统计和支付方式中的应用。

结果 提出了一套系统的康复病历标准框架，涵盖患者基本信息、康复诊断、功能评估、康复治疗处方、阶段性评估及出院总结等关键架构。分析ICD-10/ICD-11、ICF和ICHI Beta-3等工具在病案术语、编码和评估领域的系统应用方法和数据标准。构建规范化的康复病历数据结构和数据标准可以显著提升基于病案首页的康复医疗数据报送质量，从而提升康复服务质量控制水平，有效地支持优化康复医保支付机制，并有助于建立基于DRG和DIP等康复医疗绩效评估与康复支付方法体系。

结论 康复病历的结构化和数据标准化是康复质量控制的重要工具。系统地应用WHO-FICs分类标准，对标国家相关规范，构建标准化的康复病历架构与核心数据集，基于ICF方法标准化康复医疗流程，并开发基于ICD-11和ICF的康复评估工具、辅助诊断和治疗系统以及辅助术语、编码系统，能够有效提升康复病历质量，实现康复病历数据与其他医疗数据的互操作性和共享，从而提高康复服务的质量和安全性。

关键词: 康复病历, 病历数据标准化, 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 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

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