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WS/T 500.44-2016 English PDF

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WS/T 500.44-2016: Specification for sharing document of electronic medical record. Part 44: Inpatient progress note. Rescue record
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WS/T 500.44-2016English629 Add to Cart 5 days [Need to translate] Specification for sharing document of electronic medical record. Part 44: Inpatient progress note. Rescue record Valid WS/T 500.44-2016

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Standard similar to WS/T 500.44-2016

WS/T 655   WS/T 367   YBB 0008   WS/T 500.36   WS/T 500.24   WS/T 500.35   

Basic data

Standard ID WS/T 500.44-2016 (WS/T500.44-2016)
Description (Translated English) Specification for sharing document of electronic medical record. Part 44: Inpatient progress note. Rescue record
Sector / Industry Health Industry Standard (Recommended)
Classification of Chinese Standard C07
Classification of International Standard 11.020
Word Count Estimation 27,236
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
Summary This section specifies document templates for rescue records and a series of constraints on document headers and document bodies. This part is applicable to the standard collection, transmission, storage, sharing and exchange of information and the development and application of information system in electronic medical records.

WS/T 500.44-2016: Specification for sharing document of electronic medical record. Part 44: Inpatient progress note. Rescue 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 44.Inpatient progress note.Rescue record ICS 11.020C07 People's Republic of China Health Industry Standard Specification for shared electronic medical records Part 44.Record of hospitalization and rescue 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 4 6 Document body specification 6 6.1 Chapter composition 6 6.2 Diagnosis Record Chapter 6 6.3 Treatment Plan Chapter 8 6.4 Surgical operation chapter 8 6.5 Laboratory Inspection Chapter 12 Appendix A (informative appendix) Example 15 of rescue record file

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 44 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. Wuxi Hospital of Traditional Chinese Medicine, National Health and Family Planning Commission Statistical Information Center, Tongji Medical College of Huazhong University of Science and Technology. The main drafters of this section. Shen Chongde, Tong Simu, Shen Ganglei, Tang Xuejun, Zhang Lili, Shen Lining, Xiang Fei, Xu Biao. Electronic medical record sharing document specification Part 44.Inpatient course record and rescue record

1 scope

This part of WS/T 500 specifies the document template for rescue 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 rescue 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 Chapter composition The chapter structure of the business document body is shown in Table 5. 6.2 Diagnosis Record Chapter 6.2.1 The composition of the chapter entries of the diagnosis record See Table 6 for the composition of entries in the diagnostic record chapter. 6.2.2 Element composition of diagnosis record chapter The element composition of the diagnostic record chapter is shown in Table 7. 6.3 Treatment plan section 6.3.1 Article composition of treatment plan chapters See Table 8 for the composition of items in the treatment plan chapters. 6.3.2 Element composition of treatment plan chapters The element composition of the treatment plan chapter is shown in Table 9. 6.4.2 Element composition of surgical operation chapter The element composition of the surgical operation chapter is shown in Table 11. 6.5 Laboratory inspection chapter 6.5.1 The composition of laboratory inspection chapter entries The composition of items in the laboratory inspection chapter is shown in Table 12.

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