康复学报2025，Vol.35Issue(2)：124-129,6.DOI:10.3724/SP.J.1329.2025.02003
住院患者康复治疗文书书写要点专家共识
Expert Consensus on Key Writing Points for Inpatient Rehabilitation Treatment Documents
摘要
Abstract
Standardized rehabilitation treatment documents are of great significance to the clinical rehabilitation practice.At present,there is no"writing specification for rehabilitation treatment documents"available for reference,which substantially hinders the standardization and quality consistency of rehabilitation services.The development of the Expert Consensus on Key Writing Points for Inpatient Rehabilitation Treatment Documents aims to establish clear and structured guidelines for rehabilitation professionals to standardize clinical documentation practices.This expert consensus provides standardized recommendations focusing on three core aspects:fundamental principles,essential components,and key content requirements for inpatient rehabilitation documentation.The documentation should follow seven cardinal principles:standardization,comprehensiveness,objectivity,accuracy,timeliness,regula-tory compliance and authenticity.Essential documentation components encompass three chronological sections:initial evaluation re-cords,treatment progress notes,and discharge summaries.The SOAP(subjective data,objective data,assessment,plan)format is recommended as the foundational documentation framework.For initial evaluation records,the subjective section should include chief complaint,current medical history,past medical history,social history,emotional status,pain,and rehabilitation expectations;the objective section should include vital signs,consciousness level,mental status,and discipline-specific assessments(physical ther-apy,occupational therapy,speech/swallowing therapy);the assessment and analysis section should include functional diagnosis with corresponding long-term and short-term rehabilitation goals;the rehabilitation plan should include treatment protocols and relevant precautions.Treatment progress note requires systematic recording of implementation details and functional progress.Discharge summaries should include discharge diagnosis,discharge functional assessment,rehabilitation goals for the next stage,and diacharge care instructions.This expert consensus can enhance documents quality in inpatient rehabilitation,promote the standardization and homogenization of clinical practice nationwide and provide support and basis for the clinical and scientific research work of rehabili-tation.It is applicable to guiding the rehabilitation therapists in the rehabilitation wards of general hospitals,rehabilitation hospitals,and wards of community health and rehabilitation institutions to standardize the rehabilitation treatment documents.关键词
康复治疗文书/病历书写/住院患者/书写规范/专家共识Key words
rehabilitation treatment documents/medical record writing/inpatients/writing standardization/expert consensus引用本文复制引用
中国康复医学会物理治疗专业委员会,中国康复医学会作业治疗专业委员会,通信作者..住院患者康复治疗文书书写要点专家共识[J].康复学报,2025,35(2):124-129,6.基金项目
广东省中医院中医康复人才培养项目(01020184) （01020184）
康复治疗学国家一流专业建设项目(A1-2601-24-427) （A1-2601-24-427）
