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WS 445.2-2014: Basic dataset of electronic medical record. Part 2: Outpatient and emergency medical record
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Basic dataset of electronic medical record. Part 2: Outpatient and emergency medical record
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WS 445.2-2014
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Basic data | Standard ID | WS 445.2-2014 (WS445.2-2014) | | Description (Translated English) | Basic dataset of electronic medical record. Part 2: Outpatient and emergency medical record | | Sector / Industry | Health Industry Standard | | Classification of Chinese Standard | C07 | | Classification of International Standard | 11.020 | | Word Count Estimation | 18,199 | | Date of Issue | 5/30/2014 | | Date of Implementation | 10/1/2014 | | Quoted Standard | GB/T 2261.1-2003; GB/T 15657-1995; GB/T 16751.3-1997; WS 218-2002; WS 364.15-2011; WS 370-2012; WS 445.1-2013; ICD-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 data set door (emergency) medical clinic basic data set metadata attributes and attribute data elements. This section applies to the basic development guide door collection, storage and sharing of information and information sy | WS 445.2-2014: Basic dataset of electronic medical record. Part 2: Outpatient and emergency medical record
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Basic dataset of electronic medical record. Part 2. Outpatient and emergency medical record
ICS 11.020
C07
People's Republic of China health industry standards
Electronic Medical Record Basic Data Set
Part 2. Door (urgent) medical records
Part 2. Outpatientandemergencymedicalrecord
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 definitions 1
4 Dataset Attributes 1
5 Data Element Attributes 2
5.1 Data Element Common Attributes
5.2 Data Element Specific Attributes 3
5.2.1 door (emergency) medical records subset 3
5.2.2 emergency observation of the medical records subset 6
5.3 Data Element Range Code Table 11
Index 12
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 second part of WS 445.
This section mainly drafted by. Fourth Military Medical University Health Information Institute, China Medical University Shengjing Jing
Hospital, Chinese Medical Association.
The main drafters of this section. Xu Yong, Liu Danhong, Wang Xia, Pan Feng, Yang Peng, all Yu, Wang Tiequan, Lei Yongjian, Rao Keqin.
Electronic Medical Record Basic Data Set
Part 2. Door (urgent) medical records
1 Scope
This part of WS 445 specifies the dataset metadata attributes and data element attributes of the gated medical records.
This section applies to guide the door (emergency) medical records basic information 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
Classification and code of TCM syndromes GB/T 15657-1995
Chinese medicine clinical diagnosis and treatment of terminology part of the law GB/T 16751.3-1997
WS 218-2002 Health Organization (Organization) Classification and Codes
Health information data - Element code area code - Part 15. Health personnel
WS 370-2012 Health Information Basic Data Set Compilation Specifications
WS 445.1-2013 Electronic Medical Record Basic Data Set Part 1. Medical Record Summary
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 definitions
The terms and definitions defined in WS 370-2012 and WS 445.1-2013 apply to this document.
4 Dataset metadata attributes
According to WS 370-2012, the dataset metadata attributes are shown in Table 1.
Table 1 Dataset metadata attributes
Metadata Subset Metadata Item Metadata value
Identification information
Subset
Data set name Door (urgent) Medical records Basic data set
Dataset identifier HDSD00.03_V1.0
Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards
Key words door (emergency) medical records
Data set language Chinese
Identification Information Subset Dataset Classification - Category Name Health Integration
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