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WS 445.1-2014 English PDF

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WS 445.1-2014: Basic dataset of electronic medical record. Part 1: Medical record summary
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Basic data

Standard ID WS 445.1-2014 (WS445.1-2014)
Description (Translated English) Basic dataset of electronic medical record. Part 1: Medical record summary
Sector / Industry Health Industry Standard
Classification of Chinese Standard C07
Classification of International Standard 11.020
Word Count Estimation 18,121
Date of Issue 5/30/2014
Date of Implementation 10/1/2014
Quoted Standard GB/T 2261.1-2003; GB/T 2261.2-2003; GB/T 2261.4-2003; GB/T 3304-1991; GB/T 15657-1995; WS 218-2002; WS 364.3-2011; WS 364.9-2011; WS 364.11-2011; WS 364.12-2011; WS 370-2012; ICI-9-CM-3; ICD-10
Regulation (derived from) State Health Circular [2014] No. 5
Issuing agency(ies) National Health and Family Planning Commission of the People's Republic of China
Summary This Standard specifies the medical summary data sets basic data set metadata attributes and attribute data elements. This section applies to guide the development of medical summary collection, storage, sharing and information systems basic information.

WS 445.1-2014: Basic dataset of electronic medical record. Part 1: Medical record summary

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Basic dataset of electronic medical record. Part 1. Medical record summary ICS 11.020 C07 People's Republic of China health industry standards Electronic Medical Record Basic Data Set Part 1. Medical history summary Part 1. Medicalrecordsummary Posted on May 30,.2014 2014-10-01 Implementation People's Republic of China National Health and Family Planning Commission released Directory Preface Ⅰ 1 Scope 1 2 Normative references 1 3 Terms and Abbreviations 1 3.1 Terms and definitions 1 3.2 Abbreviations 1 4 Dataset Attributes 2 5 Data Element Attributes 2 5.1 Data Element Common Attributes 5.2 Data Element Specific Attributes 3 5.2.1 Basic information subset of patients 3 5.2.2 Basic Health Information Subset 5 5.2.3 Summary Subsection of Health Events 6 5.2.4 Medical Expenses Record Subset 8 5.3 Data Element Range Code Table 9 Index 11

Foreword

This standard was drafted in accordance with the rules given in GB/T 1.1-2009. WS 445 "EMR basic data set" is divided into 17 parts. --- Part 1. medical records summary; --- Part 2. Door (urgent) medical records; --- Part 3. door (urgent) consultation prescription; --- Part 4. Inspection inspection records; --- Part 5. General treatment records; --- Part 6. midwifery records; --- Part 7. Nursing operation records; --- Part 8. Nursing assessment and planning; --- Part 9. informed information; --- Part 10. Inpatient medical records home page; --- Part 11. Chinese medical records Home; --- Part 12. admission records; --- Part 13. Inpatient course records; --- Part 14. hospital doctor's advice; --- Part 15. discharge summary; --- Part 16. Referral (hospital) records; --- Part 17. Medical institutions information. This part is the first part of WS 445. This section mainly drafted by. Ministry of Health Statistics Information Center, Fourth Military Medical University Health Information Institute, China Shengjing Hospital Affiliated to Medical University, Chinese Medical Association, Huazhong University of Science and Technology Tongji Medical College. The main drafters of this section. Meng group, Hu Jianping, Tang Xuejun, innocence, Xu Yong, Liu Danhong, Wang Xia, Yang Zhe, Liang Ying, Guo Qiyong, Chen Zhongyan, Li Yanlong, Rao Keqin, Shen Ning. Electronic Medical Record Basic Data Set Part 1. Medical history summary

1 Scope

This part of WS 445 specifies the dataset metadata attributes and data element attributes of the basic set of medical records. This section applies to the guidance of basic medical records summary collection, storage, sharing and information system development.

2 Normative references

The following documents for the application of this document is essential. For dated references, only the dated version applies to this article Pieces. For undated references, the latest edition (including all amendments) applies to this document. GB/T 2261.1-2003 personal basic information classification and code - Part 1. human gender code GB/T 2261.2-2003 Personal basic information and classification code Part 2. Marital status code GB/T 2261.4-2003 Personal basic information classification and code - Part 4. Occupation category code Roman alphabetical spelling and code for the names of various nationalities in China GB/T 3304-1991 Classification and code of TCM syndromes GB/T 15657-1995 WS 218-2002 Health Organization (Organization) Classification and Codes WS 364.3-2011 Health Information Data Element Value Range Code Part 3. Demographic and Socio-economic Characteristics Health information data - Element code area code - Part 9. Laboratory tests Health information data - Element code area code - Part 11. Medical assessment Health Information Data Element Value Area Code Part 12. Planning and Intervention WS 370-2012 Health Information Basic Data Set Compilation Specifications ICD-9-CM-3 International Classification of Diseases, 9th Edition, Revision 3, Volume 3 ICD-10 International Classification of Diseases 10th Edition

3 Terms and abbreviations

3.1 Terms and definitions WS 370-2012 as defined in the following terms and definitions apply to this document. 3.1.1 Electronic medical record Medical staff in the medical process, the use of medical institutions, information systems generated by the text, symbols, diagrams, graphics, data, images, etc. Characterization of information and the ability to store, manage, transmit and reproduce medical records are records of medical records. 3.2 Abbreviations The following abbreviations apply to this document. ICD. International Classification of Diseases

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