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WS 445.4-2014 PDF English

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WS 445.4-2014: Basic dataset of electronic medical record. Part 4: Examination and laboratory test record
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Basic data

Standard ID WS 445.4-2014 (WS445.4-2014)
Description (Translated English) Basic dataset of electronic medical record. Part 4: Examination and laboratory test record
Sector / Industry Health Industry Standard
Classification of Chinese Standard C07
Classification of International Standard 11.020
Word Count Estimation 19,172
Date of Issue 5/30/2014
Date of Implementation 10/1/2014
Quoted Standard GB/T 2261.1-2003; WS 218-2002; WS 364.12-2011; 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 to check inspection records basic data set of metadata attributes and attribute data elements. This standard applies to guide the development of examination and inspection record collection, storage, sharing and inform

WS 445.4-2014: Basic dataset of electronic medical record. Part 4: Examination and laboratory test 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.
Basic dataset of electronic medical record. Part 4. Examination and laboratory test record ICS 11.020 C07 People's Republic of China health industry standards Electronic Medical Record Basic Data Set Part 4. Inspection inspection records Part 4. Examinationandlaboratorytestrecord 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 --- 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 fourth part of WS 445. This section mainly drafted by. Guangdong Provincial Hospital of Traditional Chinese Medicine, Fourth Military Medical University Health Information Institute, China People's Liberation Army PLA General Hospital. The main drafters of this section. Cheng Lan, Yi Chuan Liang, Wang Weirong, Fu Hao Yang, Xu Yong, Liu Danhong, Wang Xia, Yang Zhe, Liang Ying, Liu Lihua, Guozong Tao, Su Mingliang. Electronic Medical Record Basic Data Set Part 4. Inspection inspection records

1 Scope

This part of WS 445 specifies the data set metadata attributes and data element attributes of the inspection inspection record basic data set. This section applies to guide the inspection record inspection 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 Health Information Data Element Value Area Code Part 12. Planning and Intervention 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 Check The test record basic dataset Dataset identifier HDSD00.05_V1.0 Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards Keywords check, test Data set language Chinese Data set classification - category name health synthesis Summary of Content Information Subset Dataset The primary message generated when a patient is inspected or verified at a medical facility ...

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