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Specification for sharing document of electronic medical record - Part 8: Therapy record
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Basic data
| Standard ID | WS/T 500.8-2016 (WS/T500.8-2016) |
| Description (Translated English) | Specification for sharing document of electronic medical record - Part 8: Therapy record |
| Sector / Industry | Health Industry Standard (Recommended) |
| Classification of Chinese Standard | C07 |
| Word Count Estimation | 27,221 |
| Date of Issue | 2016-08-23 |
| Date of Implementation | 2017-02-01 |
| Regulation (derived from) | State-Health-Announcement (2016)12 |
| Issuing agency(ies) | National Health and Family Planning Commission of the People's Republic of China |
WS/T 500.8-2016: Specification for sharing document of electronic medical record - Part 8: Therapy record
---This is a DRAFT version for illustration, not a final translation. Full copy of true-PDF in English version (including equations, symbols, images, flow-chart, tables, and figures etc.) will be manually/carefully translated upon your order.
Specification for sharing document of electronic medical record-Part 8.Therapy record
ICS 11.020C07
People's Republic of China Health Industry Standard
Specification for shared electronic medical records
Part 8.Treatment Record
2016-08-23 released
Implementation of.2017-02-01
Issued by the National Health and Family Planning Commission of the People's Republic of China
Table of contents
Preface Ⅲ
1 Scope 1
2 Normative references 1
3 Terms and abbreviations 1
4 Document content structure 1
5 Document header specification 1
5.1 Document Activity Class Specification 1
5.2 Participant class specification 2
5.3 Specification for related activities 3
6 Document body specification 4
6.1 Document body chapter structure 4
6.2 Past History Chapter 5
6.3 Vital Signs Chapter 6
6.4 Admission Diagnosis Chapter 7
6.5 Treatment Plan Chapter 8
6.6 Surgical operation chapter 9
6.7 Medication Management Chapter 11
Appendix A (informative appendix) Example 14 of treatment record document
Foreword
WS/T 500 "Specifications for Shared Documents of Electronic Medical Records" is divided into the following 53 parts.
---Part 1.Summary of medical records;
---Part 2.Outpatient (emergency) medical records;
---Part 3.Emergency Observation Medical Records;
---Part 4.Western medicine prescription;
---Part 5.Chinese medicine prescription;
---Part 6.Inspection report;
---Part 7.Inspection report;
---Part 8.Treatment records;
---Part 9.General operation records;
---Part 10.Pre-anesthesia visit records;
---Part 11.Anesthesia records;
---Part 12.Post-anaesthesia visit records;
---Part 13.Blood transfusion records;
---Part 14.Pending production records;
---Part 15.Records of vaginal delivery;
---Part 16.Cesarean section records;
---Part 17.General nursing records;
---Part 18.Seriously ill (critically ill) nursing records;
---Part 19.Surgical nursing records;
---Part 20.vital signs measurement records;
---Part 21.Entry and exit records;
---Part 22.Use records of high-value consumables;
---Part 23.Admission assessment;
---Part 24.Nursing Plan;
---Part 25.Discharge assessment and guidance;
---Part 26.Informed Consent Form for Surgery;
---Part 27.Anesthesia informed consent;
---Part 28.Consent Form for Blood Transfusion Treatment;
---Part 29.Special examination and special treatment consent form;
---Part 30.Notice of Critical Illness (Severe);
---Part 31.Other informed consent forms;
---Part 32.First page of hospitalized medical records;
---Part 33.Homepage of Chinese Medicine Hospitalized Medical Record;
---Part 34.Admission records;
---Part 35.Records of admission and discharge within 24 hours;
---Part 36.Death records of hospital admission within 24 hours;
---Part 37.Record of the course of hospitalization for the first time;
---Part 38.Inpatient course records and daily course records;
---Part 39.Records of hospitalization course records of superior physicians' rounds;
---Part 40.Inpatient course record and difficult case discussion record;
---Part 41.Inpatient course record and shift record;
---Part 42.Inpatient course records and transfer records;
---Part 43.Summary of the stage of hospitalization record;
---Part 44.Records of hospitalization and rescue records;
---Part 45.Inpatient course record and consultation record;
---Part 46.Preoperative summary of hospitalization record;
---Part 47.Preoperative discussion of hospitalization record;
---Part 48.Record of the first course of illness after the hospitalization;
---Part 49.Hospitalization and Discharge Records;
---Part 50.Inpatient course record and death record;
---Part 51.Inpatient course record and death case discussion record;
---Part 52.Hospital orders;
---Part 53.Summary of discharge.
This part is Part 8 of WS/T 500.
This section was drafted in accordance with the rules given in GB/T 1.1-2009.
Drafting organizations of this section. Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Shengjing Hospital Affiliated to China Medical University, Chinese People
PLA General Hospital, Liaodong Bay Branch of Shengjing Hospital Affiliated to China Medical University.
The main drafters of this section. Chen Yanyan, Ye Qing, Chen Yongfei, Nie Lili, Yao Gang, Quanyu, Liu Lihua, Liu Yuehui, Liu Xueyong, Chen Zhongyan,
Zhang and Li Yanlong.
Electronic medical record sharing document specification Part 8.Treatment records
1 scope
This part of WS/T 500 specifies a document template for treatment records and a series of constraints on the document header and body. This section applies to the standardized collection, transmission, storage, sharing and exchange of treatment records in electronic medical records, and the development and application of information systems.
2 Normative references
The following documents are indispensable for the application of this document. For dated reference documents, only the dated version applies to this article
Pieces. For undated references, the latest version (including all amendments) applies to this document.
WS/T 482 Health Information Sharing Document Preparation Specification
3 Terms and abbreviations
The terms and abbreviations defined in WS/T 482 apply to this document.
4 Document content structure
The content composition of business documents is shown in Table 1, and examples of documents are shown in Appendix A.
5 Document header specification
5.1 Document Activity Class Specification
The composition of document activity elements and the description of the corresponding relationship with data elements are shown in Table 2.
5.2 Participant class specification
The composition of the participant class elements and the description of the corresponding relationship with the data elements are shown in Table 3.
5.3 Specifications for related activities
The composition of associated activity elements and the description of the corresponding relationship with data elements are shown in Table 4.
6 Document body specification
6.1 Document body chapter structure
The chapter structure of the document body is shown in Table 5.
6.2 Chapters of past history
6.2.1 The composition of past history chapter entries
The composition of entries in the chapters of past history is shown in Table 6.
6.3 Vital Signs Chapter
6.3.1 Composition of vital signs chapter entries
The composition of vital signs chapter entries is shown in Table 8.
6.3.2 Elemental composition of vital signs chapter
The element composition of the vital signs chapter is shown in Table 9.
6.4 Admission diagnosis chapter
6.4.1 The composition of the chapters of admission diagnosis
See Table 10 for the composition of entries in the chapter on admission diagnosis.
6.5 Treatment plan chapter
6.5.1 The composition of the chapter entries of the treatment plan
The composition of the entries in the treatment plan chapters is shown in Table 12.
6.5.2 Element composition of treatment plan chapters
The element composition of the treatment plan chapter is shown in Table 13.
6.6 Operation chapter
6.6.1 Surgery operation chapter entry composition
See Table 14 for the composition of entries in the surgical operation chapter.
6.7 Medication Management Chapter
6.7.1 Article composition of medication management chapter
The composition of the entries in the medication management chapter is shown in Table 16.
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