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WS/T 483.18-2016 PDF English

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WS/T 483.18-2016: Specification for sharing document of residents health record. Part18-Inpatient medical summary
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WS/T 483.18-2016English949 Add to Cart 7 days [Need to translate] Specification for sharing document of residents health record. Part18-Inpatient medical summary

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Basic data

Standard ID WS/T 483.18-2016 (WS/T483.18-2016)
Description (Translated English) Specification for sharing document of residents health record. Part18-Inpatient medical summary
Sector / Industry Health Industry Standard (Recommended)
Classification of Chinese Standard C07
Classification of International Standard 11.020
Word Count Estimation 41,485
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-Announcement (2016)10
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 hospitalization summary, the requirements for the document schema, and a set of constraints on the document header and body of the document. This standard applies to the application of the hospitalization summary document.

WS/T 483.18-2016: Specification for sharing document of residents health record. Part18-Inpatient medical summary




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Specification for sharing document of residents health record. Part 18-Inpatient medical summary ICS 11.020 C07 People's Republic of China health industry standards Health file sharing document specification Part 18. Inpatient abstracts Part 18. Inpatientmedicalsummary 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 2 5.3 related activities class specification 4 6 document body specification 5 6.1 Document body constitution 5 6.2 Symptoms Chapter 5 6.3 Laboratory tests Section 6 6.4 Diagnostic records chapter 8 6.5 Consultation reasons Chapter 11 6.6 Consultation Chapter 12 6.7 Medication Chapter 13 6.8 Surgery Chapter 15 6.9 Other medical treatment Chapter 17 Referral Recommendation Chapter 6.11 Health Assessment Chapter 19 6.12 Treatment Plan Chapter 20 6.13 Health Guidance Section 21 6.14 Fees Chapter 22 Appendix A (informative) Hospital summary document example 24

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 18 of the WS/T 483. This section drafted in accordance with GB/T 1.1-2009 given rules. This section Drafted by. Fourth Military Medical University Health Information Institute, Huazhong University of Science and Technology, National Health and Family Planning Commission statistics information Center. The main drafters of this section. Liu Danhong, Yang Peng, Xu Yong, Wang Xia, Pan Feng, Yang Zhe, Bai Yuxiang, Shen Lining, Tang Xuejun. Health file sharing document specification Part 18. Inpatient abstracts

1 Scope

This part of WS/T 483 specifies the document templates for inpatient abstracts, the requirements for the document structure, and the relationship between the document header and the document body Column constraint. This section is suitable for hospital 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 hospital summary document table of contents 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 Laboratory tests Section 1.1 Diagnostic record section 1.1 Reason for consultation Section 1.1 Consultation Chapter 1.1 ...

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