WS 445.14-2014Basic dataset of electronic medical record. Part 14: Inpatient order (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 the 14th part of WS 445.

This section mainly drafted by. General Hospital of Chinese People's Liberation Army, Guangdong Provincial Hospital of Traditional Chinese Medicine, Wuxi City Hospital of Chinese Medicine, Affiliated Shengjing Hospital.

1 Scope

This part of WS 445 specifies the data set metadata attributes and data element attributes of the resident physician's basic data set.

This section applies to guide the acquisition of basic information of hospital doctors, storage, sharing and development of information systems.

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 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

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.

Table 1 Dataset metadata attributes

Metadata Subset Metadata Item Metadata value Identification information Subset Data set name Resident's order Basic data set Dataset identifier HDSD00.15_V1.0 Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards Key words hospitalization Data set language Chinese Data set classification - category name health synthesis Content information Subset Dataset Summary Medical instructions given by a physician during a medical activity when a patient is hospitalized at a medical facility Dataset Features Data Element Prescription drug group number, electronic application form number, order type code, doctor's advice item Type code, the content of the doctor's advice item, the start date and time of the doctor's plan, and the doctor's order Draw the end date and time, the doctor's note information, the doctor's order opened the signature, the doctor's advice to open Legislation department, doctor's order reviewer's signature, check doctor's signature nurse, doctor's advice Signature, order execution department, order execution status, order stop date and time, Medical order cancellation date and time