WS 445.11-2014Basic dataset of electronic medical record. Part 11: Home page of inpatient medical record summary of TCM (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 section is part 11 of the WS 445.

This section mainly drafted by. Shanghai University of Traditional Chinese Medicine Shuguang Hospital (Chinese Medicine Hospital Medical Quality Monitoring Center), Guangdong Province, Chinese medicine Hospital, Wuxi City, Chinese Medicine Hospital, Fourth Military Medical University Health Information Institute, Ministry of Health Statistics Information Center.

1 Scope

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

This section is suitable for guiding the acquisition of the basic information of Chinese medical records home page, 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 GB/T 2659-2000 countries and regions in the world name code Roman alphabetical spelling and code for the names of various nationalities in China GB/T 3304-1991 GB/T 4761-2008 family relationship code 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 Value Area Code Part 12. Planning and Intervention WS 370-2012 Health Information Basic Data Set Compilation Specifications WS 445.1-2013 Electronic Medical Record Basic Data Set Part 1. Medical Record Summary 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 definitions

The terms and definitions defined in WS 370-2012 and WS 445.1-2013 apply to this document.

4 Dataset metadata attributes

According to WS 370-2012, the dataset metadata attributes are shown in Table 1.