康复学报 (Apr 2025)
Expert Consensus on Key Writing Points for Inpatient Rehabilitation Treatment Documents
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 Documentation 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, regulatory compliance and authenticity. Essential documentation components encompass three chronological sections: initial evaluation records, 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 therapy, 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 documentation 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 rehabilitation. 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 documentation.
