老年康复患者住院病案书写要点专家共识OACSTPCD

Geriatric rehabilitation is a crucial branch of rehabilitation medicine.It is important to comprehensively and accu-rately 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 for-mulation 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,underly-ing diseases,complications and comorbidities),functional diagnosis(physiological dysfunction,psychological dysfunction,ac-tivities of daily living)],rehabilitation treatment plan,medical orders[temporary medical orders(routine examination,auxiliary ex-amination and functional assessment)],long-term medical orders(routine nursing orders of the department of rehabilitation medi-cine,medication orders,and rehabilitation treatment orders,etc.)],progress notes,discharge records,and the first page of inpatient medical records.