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Basic data
| Standard ID | WS 445.16-2014 (WS445.16-2014) |
| Description (Translated English) | Basic dataset of electronic medical record. Part 16: Transfer record |
| Sector / Industry | Health Industry Standard |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.020 |
| Word Count Estimation | 9,953 |
| Date of Issue | 5/30/2014 |
| Date of Implementation | 10/1/2014 |
| Quoted Standard | GB/T 2261.1-2003; WS 218-2002; 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 referral (hospital) records basic data set data set metadata attributes and attribute data elements. This standard applies to guide referral (hospital) records the development of the collection, storage, sharing and information |
WS 445.16-2014: Basic dataset of electronic medical record. Part 16: Transfer record
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Basic dataset of electronic medical record. Part 16. Transfer record
ICS 11.020
C07
People's Republic of China health industry standards
Electronic Medical Record Basic Data Set
Part 16. Referral (hospital) records
Part 16. Transferrecord
Posted on May 30,.2014
2014-10-01 Implementation
People's Republic of China National Health and Family Planning Commission released
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 section is part 16 of the WS 445.
The main drafting of this section. Ministry of Health Statistics Information Center, General Hospital of Chinese People's Liberation Army, Chinese PLA Fourth Military Medical University
Institute of Health Information Institute.
The main drafters of this section. Hu Jianping, Liu Lihua, Feng Dan, Yao Yuan, Zhao Youyou, Wang Xia, Guozong Tao.
Electronic Medical Record Basic Data Set
Part 16. Referral (hospital) records
1 Scope
This part of WS 445 specifies the dataset metadata attributes and data element attributes of the referral (hospital) record base data set.
This section applies to guide the referral (hospital) record 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
WS 218-2002 Health Organization (Organization) Classification and Codes
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
Dataset Name Referral (hospital) records basic data set
Data Set Identifier HDSD00.17_V1.0
Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards
Key words referral, transfer
Data set language Chinese
Data set classification - category name health synthesis
Content information
Subset
Summary of data The main information generated during the referral of a patient at hospitalization
Dataset Features Data Element
Referral (hospital) date, referral reason, referral record, treatment plan, health assessment,
Rehabilitation measures guidance, transfer to the name of medical institutions, transfer out the name of the medical structure
...
