老年康复患者住院病案书写要点专家共识  

Expert Consensus on Key Points of Inpatient Medical Records Documentation for Geriatric Rehabilitation Patients

作　　者：中国康复医学会老年康复专业委员会 山林林[2,3] 王玉龙[2,3] 郑洁皎[4] Committee of Geriatric Rehabilitation of Chinese Association of Rehabilitation Medicine;WANG Yulong

机构地区：[1]不详 [2]深圳大学第一附属医院 [3]深圳市第二人民医院 [4]复旦大学附属华东医院

出　　处：《康复学报》2024年第4期336-340,348,共6页Rehabilitation Medicine

基　　金：国家重点研发计划“主动健康和老龄化科技应对”重点专项(2020YFC2008700);深圳市“医疗卫生三名工程”资助项目(SZSM202111010)。

摘　　要：老年康复是康复医学的重要分支,全面、准确地表述老年康复患者的疾病诊断、功能评定、康复治疗计划、康复医嘱以及记录康复过程中的功能变化至关重要。目前,我国康复医疗机构尚无统一的老年康复患者住院病案的书写规范。制定《老年康复患者住院病案书写要点专家共识》有助于为从事老年康复的专业技术人员规范化书写康复临床病案提供指导和参考。本专家共识对老年康复病案规范化书写的基本原则、主要内容进行制定。康复病案主要内容包括主诉和现病史、康复专科检查、诊断[疾病诊断(主要诊断、基础疾病、并发症和合并症)、功能诊断(生理功能障碍、心理功能障碍、日常生活活动能力)]、康复治疗计划、医嘱[临时医嘱(常规检查、辅助检查和功能评定)、长期医嘱(康复医学科护理常规医嘱、药物使用医嘱和康复治疗医嘱等)]、病程记录、出院记录、住院病案首页。Geriatric rehabilitation is a crucial branch of rehabilitation medicine.It is important to comprehensively and accurately document the disease diagnosis,functional assessment,rehabilitation treatment plan,rehabilitation instructions,and record functional changes during the rehabilitation process for geriatric rehabilitation patients.At present,there is no standardized protocol for documenting inpatient medical records of geriatric rehabilitation patients in rehabilitation medical institutions in China.The formulation of the"Expert Consensus on Key Points of Inpatient Medical Records Documentation for Geriatric Rehabilitation Patients"is helpful to provide guidance and reference for professionals and technical personnel engaged in geriatric rehabilitation to standardize the documentation of clinical rehabilitation records.This expert consensus mainly includes the basic principles and main contents of standardized writing of geriatric rehabilitation medical records.The main contents of rehabilitation medical records include chief complaint and present medical history,specialized rehabilitation examination,diagnosis[disease diagnosis(main diagnosis,underlying diseases,complications and comorbidities),functional diagnosis(physiological dysfunction,psychological dysfunction,activities of daily living)],rehabilitation treatment plan,medical orders[temporary medical orders(routine examination,auxiliary examination and functional assessment)],long-term medical orders(routine nursing orders of the department of rehabilitation medicine,medication orders,and rehabilitation treatment orders,etc.)],progress notes,discharge records,and the first page of inpatient medical records.

关 键 词：老年康复 住院病案 功能诊断 康复治疗 专家共识 

分 类 号：R197.323[医药卫生—卫生事业管理]