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Specification for sharing document of residents health record. Part 19: Consultation record
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Basic data
| Standard ID | WS/T 483.19-2016 (WS/T483.19-2016) |
| Description (Translated English) | Specification for sharing document of residents health record. Part 19: Consultation record |
| Sector / Industry | Health Industry Standard (Recommended) |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.020 |
| Word Count Estimation | 13,125 |
| Date of Issue | 2016-07-12 |
| Date of Implementation | 2016-12-15 |
| Quoted Standard | 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 document templates for documentary documentation, document architecture requirements, and a range of constraints on document headers and document bodies. This standard is suitable for the application of the consultation document. |
WS/T 483.19-2016: Specification for sharing document of residents health record. Part 19: Consultation record
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Specification for sharing document of residents health record. Part 19. Consultation record
ICS 11.020
C07
People's Republic of China health industry standards
Health file sharing document specification
Part 19. consultation records
Part 19. Consultationrecord
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 1
5.1 document activity class specification 1
5.2 Participant Class Specification 2
5.3 Related Activities Class Specification 3
6 Document Body Specification 4
6.1 Document body constitution 4
6.2 Consultation reasons Chapter 4
6.3 Consultation Chapter 5
Appendix A (informative) Consultation record document example 7
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 19 of the WS/T 483.
This section drafted in accordance with GB/T 1.1-2009 given rules.
This section is drafted. Tongji Medical College Affiliated Tongji Hospital of Huazhong University of Science and Technology, Shengjing Hospital Affiliated to China Medical University, Chinese people
PLA General Hospital.
The main drafters of this section. Chen Yan, Zhang Xiaoxiang, Yao Gang, Wang Huoming, Li Jin, Li Li, Yu-Fei Ye, Yeh, all Yu, Liu Lihua.
Health file sharing document specification
Part 19. consultation records
1 Scope
WS/T 483 provisions of this part of the consultation record document templates, document structure requirements as well as the first document and document body
Column constraint.
This section is suitable for consultation records 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.
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 consultation record document content 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 0.1
Document body
Reason for consultation Section 1.1
Consultation Chapter 1.1
5 document header specification
5.1 document activity class specification
Document activity class elements and their correspondence with the data element in Table 2.
...
