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Basic data
| Standard ID | WS 445.5-2014 (WS445.5-2014) |
| Description (Translated English) | Basic dataset of electronic medical record. Part 5: General therapy and treatment record |
| Sector / Industry | Health Industry Standard |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.020 |
| Word Count Estimation | 34,369 |
| Date of Issue | 5/30/2014 |
| Date of Implementation | 10/1/2014 |
| Quoted Standard | GB/T 2261.1-2003; WS 364.9-2011; WS 364.12-2011; WS 364.16-2011; 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 sets general treatment and disposal of basic data set metadata attributes and attribute data elements. This section applies to the general treatment and disposal to guide the development of the collection, storage, sharing |
WS 445.5-2014: Basic dataset of electronic medical record. Part 5: General therapy and treatment record
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Basic dataset of electronic medical record. Part 5. General therapy and treatment record
ICS 11.020
C07
People's Republic of China health industry standards
Electronic Medical Record Basic Data Set
Part 5. general treatment records
Part 5. General treatment and treatment record
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 Treatment Record Subset 3
5.2.2 General Surgical Record Subset 6
5.2.3 preoperative anesthesia visit record subset 9
5.2.4 Subset of Anesthesia Records 13
5.2.5 Post-anesthesia Visit Record Subset 17
5.2.6 Transfusion Record Subset 19
5.3 Data Element Range Code Table 23
Index 26
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 the fifth part of WS 445.
This section mainly drafted by. Ministry of Health Statistics Information Center, Shengjing Hospital Affiliated to China Medical University, General Hospital of Chinese People's Liberation Army.
The main drafters of this section. Meng group, Wang Caoyou, Tang Xuejun, Guo Qiyong, all Yu, Fan Ling, Li Tao, Xiao Li, Wang Rongli, Wang Tiequan, Lei Yongjian,
Feng Dan.
Electronic Medical Record Basic Data Set
Part 5. general treatment records
1 Scope
This part of WS 445 specifies the data set metadata attributes and data element attributes of the basic treatment record base data set.
This section applies to guide the general treatment of basic records of treatment 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
Health information data - Element code area code - Part 9. Laboratory tests
Health Information Data Element Value Area Code Part 12. Planning and Intervention
WS 364.16-2011 Health Information Data Element Value Range Code Part 16. Pharmaceuticals, Equipment and Materials
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 General Treatment Disposition Record Basic Data Set
Data Set Identifier HDSD00.06_V1.0
Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards
Key words anesthesia, treatment, surgery, blood transfusion
Data set language Chinese
Data set classification - category name health synthesis
...
