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Basic data
| Standard ID | WS 445.7-2014 (WS445.7-2014) |
| Description (Translated English) | Basic dataset of electronic medical record. Part 7: Nursing operation records |
| Sector / Industry | Health Industry Standard |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.020 |
| Word Count Estimation | 27,251 |
| Date of Issue | 5/30/2014 |
| Date of Implementation | 10/1/2014 |
| Quoted Standard | GB/T 2261.1-2013; WS 364.9-2011; 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 nursing record basic data set metadata attributes and attribute data elements. This standard applies to guide nursing record basic information about the development of the collection, storage, sharing, and information |
WS 445.7-2014: Basic dataset of electronic medical record. Part 7: Nursing operation records
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Basic dataset of electronic medical record. Part 7. Nursing operation records
ICS 11.020
C07
People's Republic of China health industry standards
Electronic Medical Record Basic Data Set
Part 7. Nursing practice records
Part 7. Nursingoperationrecords
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 General Nursing Record Subset 3
5.2.2 critically ill (re) nursing record subset 6
5.2.3 Surgical Nursing Record Subset 8
5.2.4 Vital Signs Measurement Record Subset 11
5.2.5 Outlet Record Subset 13
5.2.6 High value consumable usage record subset 15
5.3 Data Element Range Code Table 18
Index 20
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 seventh part of WS 445.
This section mainly drafted by. Shengjing Hospital Affiliated to China Medical University, Fourth Military Medical University People's Liberation Army Health Information Research
, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Chinese Medicine Hospital Medical Quality Monitoring Center).
The main drafters of this section. Guoqi Yong, all Yu, Fan Ling, Li Tao, Xiao Li, Wang Rongli, Chen Zhongyan, Zhang Chen, Li Yanlong, Wang Tiequan, Lei Yongjian,
Wang Xia, Zhou Hua, Zhu Liming, Wang Zhipi, Shi Wanzhong.
Electronic Medical Record Basic Data Set
Part 7. Nursing practice records
1 Scope
This part of WS 445 specifies the dataset metadata attributes and data element attributes for a Nursing Operations record base dataset.
This section applies to guide the basic information of nursing records 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 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
Data Set Name Care Operations Record basic data sets
Data Set Identifier HDSD00.08_V1.0
Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards
Key words
Nursing operations, sick (critically ill) care, surgical care, temperature records, access
Records, records of use of health materials
Data set language Chinese
Data set classification - category name health synthesis
...
