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WS/T 483.16-2016 PDF English

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WS/T 483.16-2016	English	RFQ	ASK	10 days [Need to translate]	Specification for sharing document of residents health record--Part 16: Adult physical examination

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Basic data

Standard ID	WS/T 483.16-2016 (WS/T483.16-2016)
Description (Translated English)	Specification for sharing document of residents health record--Part 16: Adult physical examination
Sector / Industry	Health Industry Standard (Recommended)
Classification of Chinese Standard	C07
Classification of International Standard	11.020
Word Count Estimation	110,177
Date of Issue	2016-07-12
Date of Implementation	2016-12-15
Regulation (derived from)	State-Health-Announcement (2016)10
Issuing agency(ies)	National Health and Family Planning Commission of the People's Republic of China

Similar standards

WS/T 655| WS/T 367| YBB 0008|WS/T 483.12|

WS/T 483.16-2016: Specification for sharing document of residents health record--Part 16: Adult physical examination

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Specification for sharing document of residents health record - Part 16. Adult physical examination ICS 11.020 C07 People's Republic of China health industry standards Health file sharing document specification Part 16. adult health examination Part 16. Adultphysicalexamination 2016-07-12 release 2016-12-15 Implementation People's Republic of China National Health and Family Planning Commission released Directory Foreword Ⅲ 1 Scope 1 2 Normative references 1 3 Terms and Abbreviations 1 4 The contents of the document constitute 1 5 document header specification 2 5.1 document activity class specification 2 5.2 Participant Class Specification 3 5.3 Related Activities Class Specification 5 6 document body specification 5 Section 6.1 Constitution 5 6.2 Symptoms Chapter 6 6.3 vital signs chapter 7 6.4 Oral, Throat and Tooth Chapter 12 6.5 Eye chapter 14 6.6 Ear chapter 16 6.7 Abdomen section 17 6.8 Functional check chapter 20 6.9 Heart chapter 21 6.10 Blood vessel chapter 23 6.11 Breathing System Chapter 23 6.12 skin chapter 25 6.13 Lymphatic System Chapter 26 6.14 limbs section 27 6.15 rectum chapter 28 6.16 Breast Chapter 29 6.17 Genitalia chapter 30 6.18 Laboratory examination section 33 6.19 Auxiliary Inspection Chapter 42 6.20 Diagnostic records chapter 45 6.21 Medication Chapter 47 6.22 Family history chapter 48 6.23 History of hospitalization 49 6.24 Vaccination history chapter 52 6.25 Occupational Exposure History chapter 54 6.26 Lifestyle Chapter 56 6.27 Health Assessment Chapter 61 6.28 Health Guidance Section 64 Appendix A (informative) adult health check-up document example 66

Foreword

WS/T 483 "health file sharing document specification" is divided into the following twenty parts. --- Part 1. Personal basic health information registration; --- Part 2. Birth medical certificate; --- Part 3. Newborn family visit; --- Part 4. child health examination; --- Part 5. First prenatal follow-up service; --- Part 6. Prenatal follow-up service; --- Part 7. postpartum visit; --- Part 8. Postpartum 42 days health check; --- Part 9. Vaccination reports; --- Part 10. Infectious Diseases Report; --- Part 11. Medical proof of death; --- Part 12. Hypertensive patients follow-up services; --- Part 13. Type 2 diabetes patients follow-up service; --- Part 14. Registration of personal information of patients with severe mental illness; --- Part 15. follow-up services for patients with severe mental illness; --- Part 16. Adult health examination; --- Part 17. Clinic summary; --- Part 18. Hospital summary; --- Part 19. consultation records; --- Part 20. Referral (hospital) records. This section is part 16 of the WS/T 483. This section drafted in accordance with GB/T 1.1-2009 given rules. This section drafted by. Chinese People's Liberation Army General Hospital, Tongji Medical College, Huazhong University of Science and Technology Tongji Hospital, China Medical University Subsidiary Shengjing Hospital. The main drafters of this section. Cao Xiu Tang, Liu Yuehui, Liu Lihua, Zhang Xiaoxiang, all Yu, Guo Zongtao, He Qianfeng. Health file sharing document specification Part 16. adult health examination

1 Scope

This part of WS/T 483 specifies the document template for adult health examination, the requirements of the document structure and the document header and document body A series of constraints. This section applies to the application of adult health examination documents.

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. WS/T 482 Health Information Sharing Document Preparation Specification

3 Terms and abbreviations

WS/T 482 defined terms and abbreviations apply to this document.

4 document content structure

The contents of the document are shown in Table 1, and for the document examples, see Appendix A. Table 1 business document content structure Document composition information module cardinality Document header Document Activity Class Information 1.1 Patient Information 1.1 Creator Information 1.1 Data entry information 0.1 Document Manager Information 1.1 Related activities information 0. * Document body Symptoms Chapter 1.1 Vital Signs chapter 1.1 Oral, Throat and Tooth Chapter 1.1 Eye chapter 0.1 Ear chapter 1.1 Abdomen section 1.1 ...

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