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WS/T 483.17-2016 PDF English

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WS/T 483.17-2016: Specification for sharing document of residents health record. Part 17: Outpatient medical summary
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WS/T 483.17-2016English859 Add to Cart 5 days [Need to translate] Specification for sharing document of residents health record. Part 17: Outpatient medical summary

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Basic data

Standard ID WS/T 483.17-2016 (WS/T483.17-2016)
Description (Translated English) Specification for sharing document of residents health record. Part 17: Outpatient medical summary
Sector / Industry Health Industry Standard (Recommended)
Classification of Chinese Standard C07
Classification of International Standard 11.020
Word Count Estimation 37,316
Date of Issue 2016-07-12
Date of Implementation 2016-12-15
Quoted Standard GB/T 2261.1-2003; GB/T 2261.2-2003; WS/T 482
Regulation (derived from) State-Health-Communication (2016) No.10; Industry Standard Announcement No.16 of 2016 (No.203)
Issuing agency(ies) National Health and Family Planning Commission of the People's Republic of China
Summary This standard specifies the document template for the outpatient summary, the requirements for the document architecture, and a series of constraints on the document header and document body. This standard is suitable for the application of outpatient abstract documents.

WS/T 483.17-2016: Specification for sharing document of residents health record. Part 17: Outpatient medical summary




---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.
Specification for sharing document of residents health record. Part 17. Outpatient medical summary ICS 11.020 C07 People's Republic of China health industry standards Health file sharing document specification Part 17. clinic summary Part 17. Outpatientmedicalsummary 2016-07-12 release 2016-12-15 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 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 2 5.3 related activities class specification 4 6 document body specification 5 6.1 Document body constitution 5 6.2 Major Health Issues Section 5 6.3 Symptoms Chapter 6 6.4 Laboratory tests Section 8 6.5 Diagnostic records chapter 10 6.6 Medication Chapter 11 6.7 Surgery Chapter Operation 13 6.8 Other medical treatment Chapter 15 6.9 Referral Recommendation Chapter 15 6.10 Health Assessment Chapter 17 6.11 Treatment Planning Chapter 18 6.12 Health Guidance Section 19 6.13 Fees Chapter 20 Appendix A (informative) outpatient summary document example 23

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 17 of the WS/T 483. This section drafted in accordance with GB/T 1.1-2009 given rules. This section was drafted. Fourth Military Medical University Institute of Health Information, Fourth Military Medical University Xijing Hospital, Huazhong University of Science and Technology Tongji Medical College The main drafters of this section. Yang Peng, Yong Yong, Liu Danhong, Wang Xia, Pan Feng, Liu Ya, He Wei, Shen Ning. Health file sharing document specification Part 17. clinic summary

1 Scope

This part of WS/T 483 specifies the document templates for outpatient summaries, the requirements for the document architecture, and the relationship between the document header and the document body Column constraint. This section is suitable for out-patient summary document application.

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 GB/T 2261.2-2003 Personal basic information classification and code Part 2. Marital status code 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 outpatient summary document content composition table 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 Major Health Issues Chapter 1.1 Symptoms Chapter 1.1 Laboratory tests Section 1.1 Diagnostic record section 1.1 ...

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