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Medical transfer records from pre-hospital medical organization to emergency department of hospital
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Basic data
| Standard ID | WS/T 621-2018 (WS/T621-2018) |
| Description (Translated English) | Medical transfer records from pre-hospital medical organization to emergency department of hospital |
| Sector / Industry | Health Industry Standard (Recommended) |
| Classification of Chinese Standard | C05 |
| Word Count Estimation | 9,989 |
| Date of Issue | 2018-09-26 |
| Date of Implementation | 2019-04-01 |
| Regulation (derived from) | National Health Newsletter (2018) 22 |
| Issuing agency(ies) | National Health Commission |
WS/T 621-2018: Medical transfer records from pre-hospital medical organization to emergency department of hospital
---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.
Medical transfer records from pre-hospital medical organization to emergency department of hospital
ICS 11.020
C 05
WS
People's Republic of China Health Industry Standard
Pre-hospital emergency department and hospital emergency department patients' condition
Handover order
Medical transfer records from pre-hospital medical organization to emergency
Department of hospital
2018 - 09 - 26 released
2019 - 04 - 01 Implementation
National Health and Wellness Committee of the People's Republic of China
Foreword
This standard was drafted in accordance with the rules given in GB/T 1.1-2009.
This standard was drafted. Peking Union Medical College Hospital of Chinese Academy of Medical Sciences, Beijing Emergency Center, Ruijin, Shanghai Jiao Tong University School of Medicine
Hospital, China-Japan Friendship Hospital, Ningxia Medical University General Hospital.
Drafters of this standard. Wang Zhong, Wan Lidong, Zhu Huadong, Yang Lishan, Lu Yiming, Qi Zhiwei, Xu Tengda, Zhang Wei, Ding Ning, Lu Zhongqiu,
Zhou Rongbin, Chu Yingjie, Han Jiyuan, Zhao Xiaodong, Zeng Hongke, Chai Yanfen, Peng Peng, Feng Jianhong.
Pre-hospital emergency department and hospital emergency department patient's conditional transfer order
1 Scope
This standard stipulates the paper tolerance, writing format, content and the patient's conditional transfer order when the patient is transferred from the pre-hospital emergency department to the hospital emergency department.
Storage and other requirements.
This standard is applicable to the medical staff established and used by medical staff in pre-hospital emergency institutions at all levels of the country and hospital emergency departments.
Orders.
2 Normative references
The following documents are indispensable for the application of this document. In the following documents, dated references are only dated versions.
This applies to this document; for undated references, the latest edition (including all amendments) applies to this document.
WS/T 390-2012 Hospital emergency department standardization process
DA/T 11 Document Paper Durability Test Method
DA/T 16 archival material durability test method
3 Terms and definitions
The following terms and definitions apply to this document.
3.1
Pre-hospital first aid institution and hospital emergency department patient transfer record from pre-hospital
Medical organization to emergency department of hospital
Pre-hospital emergency physicians' written records of treatment, treatment, treatment response, and precautions in the pre-hospital emergency
Hereinafter referred to as the transfer order).
4 Technical requirements for handing over paper durability and recording pen
The technical requirements for the transfer of single-recording paper should meet the technical requirements for general durable paper in DA/T 11.
The blackout pen or black-and-blue pen should be used for the transfer order record, and the ordinary "ballpoint pen" should not be used.
5 Transfer order writing requirements
5.1 The transfer order shall be at least three copies. The patient, the pre-hospital emergency department, and the receiving hospital shall each hold one copy, and the copy paper may be applied.
5.2 The durability of writing materials such as ink, signature ink and carbon paper for writing the transfer order should meet the requirements of DA/T 16.
5.3 The various records in the handover order should use Chinese simplified or universal foreign language abbreviations, without the symptoms, signs and disease names of the official Chinese translation.
We can use foreign texts.
5.4 All kinds of records should be written in accordance with the medical terminology, the text is neat, the writing is clear, the expression is accurate, the statement is fluent, and the punctuation is correct.
5.5 When a typo occurs during the writing of the transfer order, the double horizontal line is applied to the typo, and the original record is kept clear and identifiable. The modified person is modifying
Signature, and indicate the date of modification and the specific time (accurately to the point), should not be masked or removed by scraping, sticking, coating, etc.
Handwriting.
5.6 The higher-level medical staff has the responsibility to review and revise the transfer order written by the lower-level medical staff, but the written transfer order content should not be altered.
The transfer order should be signed by the primary emergency physician. The delivery order written by the intern medical staff and the medical staff during the probation period shall pass through the medical machine.
The registered medical staff (with doctors) review, identify and sign.
5.7 Printed Delivery Orders are the various records that are generated and printed using word processing software (such as Word documents, WPS documents, etc.).
The printed delivery order shall be entered in accordance with the requirements of this standard and printed in time, signed by the appropriate medical staff. Medical institution
The printed delivery order should be unified with paper, font, font size and typesetting format. The printed writing should be clear and easy to recognize, and the paper should conform to DA/T.
11 Technical requirements for general durable paper. The printed delivery order should be modified in accordance with the permission requirements during the editing process.
The transfer order printed and signed shall not be altered. If the entry error is found, it shall be modified according to the modification requirements of 5.5 of this standard.
6 Transfer order content requirements
6.1 Overview
The delivery order shall be timely, truthful, objective, accurate, complete and standardized. The content should include general information and medical information of the patient.
Annex A.
6.2 Pre-hospital first aid institution name
The name of the pre-hospital emergency agency responsible for transshipment should be indicated on the handover order.
6.3 General information and transfer information of patients
The general information of the patient in the transfer order should include name, gender, age, location of the disease, transfer to the hospital, delivery time, and emergency vehicle number.
6.3.1 Name
The name displayed on the patient's valid ID. If the patient is unable to provide a valid ID, they can be recorded by the name provided by the patient.
Verify with a valid ID. Patients who are unconscious and do not carry a valid ID with them may be given a unique logo or
No., when the patient's valid identity information is obtained, correct it.
6.3.2 Gender
The gender of the patient in the delivery order should be the same as the gender in the valid ID provided by the patient.
6.3.3 Age
The age in the delivery order is based on the age of the date of birth of the valid ID. Emergency rescue can be provided by patient or family
The age or date of birth is determined. Adults and post-school children, adolescents are accurate to (week) age; newborns should be accurate to the day; infants
It should be accurate to the month; children and preschool children should also be accurate to the moon.
6.3.4 Location of the disease
The place where the patient's disease or trauma occurs. The location of the disease should be written to the district, street, and house number. If there is no exact number of the house number,
Write as much as possible in detail.
6.3.5 Delivery time
The pre-hospital emergency department will send the patient to the hospital, and the hospital emergency department will accept the patient's time. At this time, the time of emergency registration or emergency rescue
The time of receiving the patient is the standard. The recording method should use Arabic numerals, accurately write the date and time (accurately to the minute), and the time is 24 h.
Recording.
6.3.6 Delivery to the hospital
The hospital where the patient was served. The record should include the name of the hospital and the name of the department, for example. XXX Hospital Emergency Department.
6.3.7 Emergency vehicle number
The emergency vehicle number of the patient should be stated.
6.4 Medical information
6.4.1 Initial diagnosis and disease judgment
The “impression diagnosis” obtained after the examination of the patient is recorded as a preliminary diagnosis on the handover order, and the diagnosis should be carried out in a textual manner.
recording. The patient's disease severity was determined according to the four-level triage criteria (see WS/T 390-2012) and recorded on the delivery slip.
6.4.2 Physical examination
The physical examination of the patient in the transfer order includes. body temperature, pulse, respiratory rate, blood pressure, consciousness, and trauma. Body temperature in Celsius
Degree expression, blood pressure is expressed in millimeters of mercury. Consciousness should include waking, lethargy, blurring, paralysis, lethargy, shallow coma, and deep coma.
All selected items are marked with “√” and the count should be written in Arabic numerals. Patients with trauma should indicate the location of the trauma and the type of trauma. except
Outside of body temperature, all other items should be completed.
6.4.3 Auxiliary inspection
The auxiliary examinations in this standard include rapid blood glucose examination, blood oxygen saturation examination and electrocardiogram examination, and the inspection results are recorded in the handover order.
Counts are always written in Arabic numerals. If there is an ECG handover, a “√” record should be placed on the handover order.
6.4.4 Treatment measures
In the handover order, the treatment should be as clear as possible. Use the "√" method to indicate the general treatments used, including. ECG monitoring,
Oxygen inhalation, external pacing, defibrillation, cardiopulmonary resuscitation, balloon mask ventilation, tracheal intubation, mechanical ventilation, trauma treatment, etc. Medication and
Precautions and the like should be described in words or in the form of a doctor's advice. Whenever time permits, the contents of the precautions should be written as detailed as possible.
Such as the specific time and method of treatment, the type of tracheal intubation, the treatment mode of mechanical ventilation and parameters.
6.4.5 Other records
The transfer order shall indicate the identity of the patient accompanying person by means of “√”. Patients referred from the hospital should also be indicated by Arabic numerals
The total amount of fluid carried by the patient and the balance to the destination hospital. If the patient has a connecting tube in the body, the type, location, and
Whether it is smooth and whether there is inflammation in the local area.
6.4.6 Signature of pre-hospital emergency personnel
After handing over the patient, the pre-hospital emergency personnel should clearly state the full name signature.
6.4.7 Hospital admission physician or nurse signature
After receiving the patient, the hospital attending physician or nurse should clearly state the full name signature.
7 Storage of transfer orders
This transfer order is not part of the hospital's medical record management, but the hospital should be kept for more than 3 years according to the formal medical documents, the management location and responsible
The department is implemented in accordance with the regulations of the hospital.
AA
Appendix A
(normative appendix)
Pre-hospital emergency department and hospital emergency department
Please refer to Table A.1 for the pre-hospital emergency department and hospital emergency department.
Table A.1 ××× Emergency Center and Hospital Emergency Department Handover Form
Name
□ male
□ female
Car number
Estimated time of onset
Delivery time is transferred to the hospital on the day, month and day
Initial diagnosis of illness □ endangered □ critical □ emergency □ non-emergency □ has died
Inspection records.
Before the ambulance. T °C, P times/min, R times/min, BP/mmHg
Transit. T °C, P times/min, R times/min, BP/mmHg
Junction. T °C, P times/min, R times/min, BP/mmHg
Consciousness. □ A (awake) □ V (responsive to language) □ P (reactive to painful stimuli) □ U (no response to any stimulus)
Trauma. □ Cranial cerebral □ Maxillofacial □ Neck □ Chest □ Abdominal □ Back □ Waist □ Pelvis □ Spine □ Limb □ Other
Type of injury. □ Car accident injury □ Falling injury □ Falling injury □ Burn □ Blade injury □ Blunt injury □ Gunshot □ Other
Others. Accompanying staff □ Family □ friends □ No escort □ Others
Infusion. crystal 1 total amount of allowance; crystal 2 total amount of balance
Colloid 1 total amount remaining; crystal colloid 2 total amount
In vivo connecting tube. patency of local complications
The most obvious symptoms and signs.
Auxiliary examination. blood glucose mmol/L, pulse oximetry %, other
ECG. □ Yes (□ Delivery to hospital □ Not paid to hospital) □ No ECG
ECG monitoring chart. □ Yes (□交□未交医院) □无
first-aid
□ ECG monitoring
□ Oxygen absorption
□ Start cardiopulmonary resuscitation (time)
□ External pacing (time division)
□ Defibrillation (time division)
□ Defibrillation (time division)
□ Defibrillation (time division)
medical treatement
Precautions
□ Termination of recovery (time division)
□ Balloon mask ventilation
□ Tracheal intubation
□ Mechanical ventilation
□ neck support
□ Stop bleeding (time is enabled)
□ dressing
□ fixed
□ other
signature
□ 120
□ other
Pre-hospital emergency personnel.
Date. Time.
Hospital attending physician □ Nurse. □
Signature. Date. Time.
...
