WS 445.1-2014Basic dataset of electronic medical record. Part 1: Medical record summary (English PDF)

Foreword

This standard was drafted in accordance with the rules given in GB/T 1.1-2009.

WS 445 "EMR basic data set" is divided into 17 parts.

--- Part 1. medical records summary;

--- Part 2. Door (urgent) medical records;

--- Part 3. door (urgent) consultation prescription;

--- Part 4. Inspection records;

--- Part 5. General treatment records;

--- Part 6. midwifery records;

--- Part 7. Nursing operation records;

--- Part 8. Nursing assessment and planning;

--- Part 9. informed information;

--- Part 10. Inpatient medical records home page;

--- Part 11. Chinese medical records Home;

--- Part 12. admission records;

--- Part 13. Inpatient course records;

--- Part 14. hospital doctor's advice;

--- Part 15. discharge summary;

--- Part 16. Referral (hospital) records;

--- Part 17. Medical institutions information.

This part is the first part of WS 445.

This section mainly drafted by. Ministry of Health Statistics Information Center, Fourth Military Medical University Health Information Institute, China Shengjing Hospital Affiliated to Medical University, Chinese Medical Association, Huazhong University of Science and Technology Tongji Medical College.

1 Scope

This part of WS 445 specifies the dataset metadata attributes and data element attributes of the basic set of medical records.

This section applies to the guidance of basic medical records summary collection, storage, sharing and information system development.

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 and classification code Part 2. Marital status code GB/T 2261.4-2003 Personal basic information classification and code - Part 4. Occupation category code Roman alphabetical spelling and code for the names of various nationalities in China GB/T 3304-1991 Classification and code of TCM syndromes GB/T 15657-1995 WS 218-2002 Health Organization (Organization) Classification and Codes WS 364.3-2011 Health Information Data Element Value Range Code Part 3. Demographic and Socio-economic Characteristics Health information data - Element code area code - Part 9. Laboratory tests Health information data - Element code area code - Part 11. Medical assessment Health Information Data Element Value Area Code Part 12. Planning and Intervention WS 370-2012 Health Information Basic Data Set Compilation Specifications ICD-9-CM-3 International Classification of Diseases, 9th Edition, Revision 3, Volume 3 ICD-10 International Classification of Diseases 10th Edition

3 Terms and abbreviations