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Specification for sharing document of residents health record. Part 4: Children physical examination
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Basic data
| Standard ID | WS/T 483.4-2016 (WS/T483.4-2016) |
| Description (Translated English) | Specification for sharing document of residents health record. Part 4: Children physical examination |
| Sector / Industry | Health Industry Standard (Recommended) |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.020 |
| Word Count Estimation | 55,576 |
| 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 the child health examination document template, document architecture requirements, and a series of constraints on the document header and document body. This standard is suitable for the application of children's health examination documents. |
WS/T 483.4-2016: Specification for sharing document of residents health record. Part 4: Children physical examination
---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 4.Children physical examination
ICS 11.020C07
People's Republic of China Health Industry Standard
Health File Sharing Document Specification
Part 4.Child Health Checkup
2016-07-12 released
2016-12-15 implementation
Issued by the National Health and Family Planning Commission of the People's Republic of China
Table of contents
Preface Ⅲ
1 Scope 1
2 Normative references 1
3 Terms and abbreviations 1
4 Document content structure 1
5 Document header specification 2
5.1 Document Activity Class Specification 2
5.2 Participant class specification 3
5.3 Specification for related activities 4
6 Document body specification 4
6.1 Document body chapter structure 4
6.2 Vital Signs Chapter 5
6.3 General appearance chapter 6
6.4 Skin Chapter 8
6.5 Head Chapter 9
6.6 Neck Chapter 11
6.7 Eye Chapter 12
6.8 Ear Chapter 15
6.9 Mouth, Throat and Teeth Chapter 17
6.10 Heart Chapter 18
6.11 Respiratory System Chapter 19
6.12 Abdomen Chapter 21
6.13 Limbs Chapter 22
6.14 Spine Chapter 23
6.15 Genitals Chapter 24
6.16 Chapter 25 Rectal
6.17 Chapter 26 of Child Health History
6.18 Laboratory Inspection Chapter 28
6.19 Medication Chapter 28
6.20 Health Assessment Chapter 29
6.21 Health Guidance Chapter 31
6.22 Referral Recommendation Section 32
6.23 Next follow-up arrangement Chapter 34
Appendix A (informative appendix) Example of child health examination document 35
Foreword
WS/T 483 "Health File Sharing Document Specification" is divided into the following 20 parts.
---Part 1.Personal basic health information registration;
---Part 2.Birth medical certificate;
---Part 3.Family visits for newborns;
---Part 4.Children's health examination;
---Part 5.First prenatal follow-up service;
---Part 6.Prenatal follow-up service;
---Part 7.Postpartum visit;
---Part 8.Health check on 42 days after delivery;
---Part 9.Vaccination report;
---Part 10.Infectious Disease Report;
---Part 11.Death medical certificate;
---Part 12.Follow-up service for patients with hypertension;
---Part 13.Follow-up service for patients with type 2 diabetes;
---Part 14.Personal information registration of patients with severe mental illness;
---Part 15.Follow-up service for patients with severe mental illness;
---Part 16.Adult health examination;
---Part 17.Outpatient summary;
---Part 18.Hospitalization Summary;
---Part 19.Consultation records;
---Part 20.Referral (hospital) records.
This part is part 4 of WS/T 483.
This section was drafted in accordance with the rules given in GB/T 1.1-2009.
Drafting organizations of this section. National Health and Family Planning Commission Statistical Information Center, Tongji Medical College of Huazhong University of Science and Technology, Chinese Diseases
Prevention and Control Center Maternal and Child Health Center.
The main drafters of this section. Tang Xuejun, Shen Lining, Gan Liping, Pan Xiaoping, Hu Jianping, Ma Jingdong.
Health File Sharing Document Specification
Part 4.Child Health Checkup
1 scope
This part of WS 483/T stipulates the requirements for the child health examination document template, document structure, and the document header and body.
Series constraints.
This part is suitable for the application of children's health examination documents.
2 Normative references
The following documents are indispensable for the application of this document. For dated reference documents, only the dated version applies to this article
Pieces. For undated references, the latest version (including all amendments) applies to this document.
WS 482/T Health Information Sharing Document Preparation Specification
3 Terms and abbreviations
The terms and abbreviations defined by WS 482/T apply to this document.
4 Document content structure
The composition of the document content is shown in Table 1, and the document example is shown in Appendix A.
5 Document header specification
5.1 Document Activity Class Specification
The composition of document activity elements and their correspondence with data elements are shown in Table 2.
5.2 Participant class specification
The composition of participant class elements and the corresponding relationship with data elements are shown in Table 3.
5.3 Specifications for related activities
The specification element composition of the associated activity class and the corresponding relationship with the data element are shown in Table 4.
6.2 Vital Signs Chapter
6.2.1 Composition of vital signs chapter entries
See Table 6 for the composition of entries in the vital signs chapter.
6.3.2 General appearance chapter element composition
The element composition of the general appearance section is shown in Table 9.
6.5 Head Chapter
6.5.1 The composition of head chapter entries
The composition of head chapter entries is shown in Table 12.
6.6 The neck section
6.6.1 The composition of neck chapter entries
The composition of the neck chapter entries is shown in Table 14.
6.7 Eye chapter
6.7.1 The composition of eye chapter entries
The composition of eye chapter entries is shown in Table 16.
6.8 Ear chapter
6.8.1 The composition of ear chapter entries
The composition of the entries in the anti-ear chapter is shown in Table 18.
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