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Specification for sharing document of residents health record. Part 5: First prenatal follow-up visit service
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Basic data
| Standard ID | WS/T 483.5-2016 (WS/T483.5-2016) |
| Description (Translated English) | Specification for sharing document of residents health record. Part 5: First prenatal follow-up visit service |
| Sector / Industry | Health Industry Standard (Recommended) |
| Classification of Chinese Standard | C07 |
| Classification of International Standard | 11.029 |
| Word Count Estimation | 59,572 |
| Date of Issue | 2016-07-12 |
| Date of Implementation | 2016-12-15 |
| Quoted Standard | GB/T 4761-2008; 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 first prenatal follow-up service record, 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 the first prenatal follow-up service record document. |
WS/T 483.5-2016: Specification for sharing document of residents health record. Part 5: First prenatal follow-up visit service
---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 5.First prenatal follow-up visit service
ICS 11.029C07
People's Republic of China Health Industry Standard
Health File Sharing Document Specification
Part 5.First prenatal follow-up service
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 definitions 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 5
6.1 Document body chapter structure 5
6.2 Chapter 5 of Maternity History
6.3 Chapter 9 of Past History
6.4 Family History Chapter 11
6.5 Vital Signs Chapter 13
6.6 Heart Chapter 15
6.7 Respiratory System Chapter 16
6.8 Genitals Chapter 18
6.9 Laboratory Inspection Chapter 21
6.10 Auxiliary Inspection Chapter 29
6.11 Health Assessment Chapter 30
6.12 Health Guidance Chapter 31
6.13 Referral Recommendation Section 32
6.14 Next follow-up arrangement Chapter 34
Appendix A (informative appendix) Sample 36 of the first prenatal follow-up service document
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 5 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, Hunan Province Maternal and Child Health Hospital.
The main drafters of this section. Hu Jianping, Shen Lining, Wei Tong, Pan Xiaoping, Wu Jiuling, Wang Ailing, Du Qiyun, Xie Donghua, Xu Dejun.
Health Record Sharing Document Specification Part 5.First Prenatal Follow-up Service
1 scope
This part of WS/T 483 specifies the document template, document structure requirements for the first prenatal follow-up service record, and the
A series of constraints on the body of the document.
This section is suitable for the application of service record documents for the first prenatal follow-up.
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.
3 Terms and definitions
The following terms and definitions defined in WS/T 482 apply to this document.
3.1
recording.
4 Document content structure
The contents of the document are shown in Table 1, and examples of documents are 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.
6 Document body specification
6.1 Document body chapter structure
The chapter structure of the document body is shown in Table 5.
6.2 Chapter of Maternity History
6.2.1 Chapter Entry Composition of Maternity History
See Table 6 for the composition of entries in the chapters on maternity history.
6.2.2 Elemental composition of chapters on maternity history
The element composition of the chapters of maternity history is shown in Table 7.
6.3 Chapters of past history
6.3.1 The composition of past history chapter entries
The composition of entries in the chapters of past history is shown in Table 8.
6.3.2 Element composition of past history chapters
The element composition of past history chapters is shown in Table 9.
6.4 Chapter Family History
6.4.1 The composition of family history chapter entries
The composition of family history chapter entries is shown in Table 10.
6.4.2 Elemental composition of family history chapters
The element composition of the family history chapter is shown in Table 11.
6.5 chapter on vital signs
6.5.1 The composition of vital signs chapter entries
The composition of vital signs chapter entries is shown in Table 12.
6.6 Heart chapter
6.6.1 The composition of heart chapter entries
6.7 Respiratory system chapter
6.7.1 Respiratory system chapter entry composition
The composition of the entries in the respiratory system chapter is shown in Table 16.
6.8 Genitals chapter
6.8.1 The composition of genital chapter entries
The composition of genital chapter entries is shown in Table 18.
6.8.2 Element composition of genitals chapter
The element composition of the genitals chapter is shown in Table 19.
6.9 Laboratory inspection chapter
6.9.1 Chapter Item Composition of Laboratory Inspection
The composition of items in the laboratory inspection chapter is shown in Table 20.
6.9.2 Elemental composition of laboratory inspection chapter
The element composition of the laboratory inspection chapter is shown in Table 21.
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