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Geriatric rehabilitation is a crucial aspect of rehabilitative medicine. It is crucial to comprehensively and accurately express the disease diagnosis, functional assessment, rehabilitation treatment plan, rehabilitation instructions, and record functional changes during the rehabilitation process for elderly rehabilitation patients. Currently, there is no standardized protocol for documenting inpatient medical records of geriatric rehabilitation patients in China's rehabilitation medical institutions. The development of the "Expert Consensus on the Key Points of Writing Medical Records for Geriatric Rehabilitation Patients" provides guidance and serves as a reference for professionals in geriatric rehabilitation, aiming to establish standardized writing for clinical rehabilitation records. This expert consensus establishes the fundamental principles and main content for standardized documentation of geriatric rehabilitation records. The main content of rehabilitation records includes chief complaint and present medical history, specialized rehabilitation examination, diagnosis (including disease diagnosis, underlying conditions, complications, and comorbidities), functional diagnosis (covering physiological and psychological functional impairments, as well as activities of daily living), rehabilitation treatment plan, medical instructions (including temporary instructions for routine examinations, auxiliary examinations, and functional assessments; long-term instructions for routine medical care, medication use, and rehabilitation treatment), treatment progress records, discharge records, and inpatient medical record cover page. |
