T/SRMA 15-2022 Rehabilitation hospitalization case record form writing guideline

Scope

Scope: This document provides guidelines for filling in the first page of rehabilitation inpatient medical records, including the basic requirements for writing the first page of rehabilitation medical inpatient medical records, the filling-in norms, and the coding rules. This document is applicable to the writing of the first page of rehabilitation medical inpatient medical records in general hospitals and specialized hospitals (including rehabilitation hospitals). Main technical content: Based on the basic principles of rehabilitation medicine and the ICF concept, and referring to the "Quality Standards for Filling in the First Page of Inpatient Medical Records (Trial)" issued by the General Office of the National Health Commission, the "Indicators for Quality Management and Control of First Page Data of Inpatient Medical Records (2016 Edition)" issued by the National Health Commission, the "Basic Standards for Medical Record Writing", the "National Clinical Edition 2.0 of Disease Classification and Codes", and the "National Clinical Edition 3.0 of Surgical Operation Classification Codes", this document specifies the general principles and special selection principles for writing the first page of medical records, selecting discharge diagnoses, and coding surgical (operative) procedures, ensuring the standardization of the content of relevant information items and the homogeneity of data.

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