Standardization of rehabilitation medical cards for adult patients with musculoskeletal and peripheral nervous systems dysfunction

Abstract

Currently, each rehabilitation institution solves the problem of registration of rehabilitation medical records empirically, based on the existing realities of a particular institution.

The study examined the development of a medical history template for the in- and outpatient medical rehabilitation of patients with peripheral nervous system (PNS) and musculoskeletal system (MSA) dysfunction.

The medical history template corresponded to the currently approved forms 003/y (“Medical record for inpatient care”) and 025/y (“Medical record for outpatient care”) but supplemented with chapters, allowing entry of information in accordance with the requirements of the Ministry of Health of the Russian Federation Order for medical rehabilitation of adults (No. 788n dated July 31, 2020). Additional chapters, forms, and appendices designed to include specific information about the rehabilitation process included the physical and rehabilitation medicine doctor examination list, multidisciplinary rehabilitation team members, examination lists, rehabilitation routing scale blank, list of MDRC discussions, individual patient management forms, standard rehabilitation discharge form, and list of rehabilitation quality criteria for adult patients with MSA/PNS dysfunction. Validated scales and test forms were also included.

The unification of rehabilitation medical records for patients with MSA/PNS impairment makes it easier for the staff of the rehabilitation departments and centers to file medical records in accordance with the current legislation.

Keywords

medical rehabilitation / medical records / musculoskeletal system / peripheral nervous system / standardization

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