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WS/T 500.17-2016: Specification for sharing document of electronic medical record - Part 17: General nursing record
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Specification for sharing document of electronic medical record - Part 17: General nursing record
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WS/T 500.17-2016
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Basic data | Standard ID | WS/T 500.17-2016 (WS/T500.17-2016) | | Description (Translated English) | Specification for sharing document of electronic medical record - Part 17: General nursing record | | Sector / Industry | Health Industry Standard (Recommended) | | Classification of Chinese Standard | C07 | | Word Count Estimation | 39,388 | | 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 500.17-2016: Specification for sharing document of electronic medical record - Part 17: General nursing record
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Specification for sharing document of electronic medical record-Part 17.General nursing record
ICS 11.020C07
People's Republic of China Health Industry Standard
Specification for shared electronic medical records
Part 17.General nursing records
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 2
5.1 Document Activity Class Specification 2
5.2 Participant class specification 3
5.3 Specification for related activities 4
6 Document body specification 6
6.1 Document body chapter composition 6
6.2 Diagnosis Record Chapter 6
6.3 Allergy History Chapter 7
6.4 Vital Signs Chapter 8
6.5 Limbs Chapter 11
6.6 Health Assessment Chapter 12
6.7 Health Guidance Chapter 13
6.8 Nursing Record Chapter 14
6.9 Nursing Observation Chapter 18
6.10 Chapter 19 of Nursing Operations
6.11 Operation Evaluation Record Mark Chapter 20
6.12 Nursing Isolation Chapter 22
Appendix A (informative appendix) Example of general nursing record document 24
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 17 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 Medical College of Huazhong University of Science and Technology, Union Hospital of Tongji Medical College of Huazhong University of Science and Technology, Chinese People’s
Fangjun General Hospital, Institute of Health Information, Fourth Military Medical University.
The main drafters of this section. Ma Jingdong, Shen Lining, Chen Min, Zhou Bin, Liu Lihua, Yao Yuan, Xu Yongyong, Xu Dejun, Yang Xuena, Xu Chunhua,
Tuo Bingbing.
Specification for shared electronic medical records
Part 17.General nursing records
1 scope
This part of WS/T 500 specifies a document template for general nursing records and a series of constraints on the document header and body.
This part is applicable to the standardized collection, transmission, storage, sharing and exchange of general nursing records in electronic medical records and the development of information systems
application.
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.
6.2.2 Element composition of diagnosis record chapter
The element composition of the diagnostic record chapter is shown in Table 7.
6.3 Allergy history chapter
6.3.1 Entry composition of allergy history chapter
The composition of allergy history chapter entries is shown in Table 8.
6.4 Vital Signs Chapter
6.4.1 Composition of vital signs chapter entries
The composition of the entries in the vital signs chapter is shown in Table 10.
Table 10 Composition of chapter entries for vital signs
Item name cardinality constraint description
Weight item 1.1 R The measured value of weight, the unit of measurement is kg
Body temperature entry 1.1 R The measured value of body temperature, the unit of measurement is ℃
Respiration rate entry 1.1 R The number of breaths per unit time, the unit of measurement is times/min
Pulse rate entry 1.1 R The measured value of the number of pulses per unit time, the unit of measurement is times/min
Blood pressure item 1.1 R The measurement value of systolic/diastolic blood pressure, the unit of measurement is mmHg
Blood oxygen saturation item 1.1 R The measurement value of blood oxygen saturation, the unit of measurement is%
6.4.2 Elemental composition of vital signs chapter
The element composition of the vital signs chapter is shown in Table 11.
6.5 Chapter Limbs
6.5.1 The composition of limbs chapter entries
The composition of the entries in the limbs chapter is shown in Table 12.
6.6 Health Assessment Section
6.6.1 Article composition of health assessment chapters
See Table 14 for the composition of items in the health assessment chapter.
6.7 Health Guidance Chapter
6.7.1 Composition of Health Guidance Chapter Items
See Table 16 for the composition of items in the health guidance chapter.
6.8 Nursing Record Chapter
6.8.1 The composition of chapter entries in nursing records
The composition of the chapter entries of nursing records is shown in Table 18.
6.9 Nursing Observation Chapter
6.9.1 Article composition of nursing observation chapter
The composition of items in the nursing observation chapter is shown in Table 20.
6.10 Nursing operation chapter
6.10.1 Nursing operation chapter entry composition
The composition of the entries in the nursing operation chapter is shown in Table 22.
6.11 Chapter of Operation Evaluation Record Mark
6.11.1 The composition of the chapter entries of the surgical evaluation record mark
See Table 24 for the composition of the chapter entries of the surgical evaluation record flag.
6.11.2 The element composition of the mark chapter of the surgical evaluation record
See Table 25 for the element composition of the marker chapter of the surgical evaluation record.
6.12.1 The composition of items in the nursing isolation chapter
The composition of the entries in the nursing isolation chapter is shown in Table 26.
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