WS 445.2-2014Basic dataset of electronic medical record. Part 2: Outpatient and emergency medical record (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 second part of WS 445.

This section mainly drafted by. Fourth Military Medical University Health Information Institute, China Medical University Shengjing Jing Hospital, Chinese Medical Association.

1 Scope

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

This section applies to guide the door (emergency) medical records basic information 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 Classification and code of TCM syndromes GB/T 15657-1995 Chinese medicine clinical diagnosis and treatment of terminology part of the law GB/T 16751.3-1997 WS 218-2002 Health Organization (Organization) Classification and Codes Health information data - Element code area code - Part 15. Health personnel 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.

Table 1 Dataset metadata attributes

Metadata Subset Metadata Item Metadata value Identification information Subset Data set name Door (urgent) Medical records Basic data set Dataset identifier HDSD00.03_V1.0 Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards Key words door (emergency) medical records Data set language Chinese Identification Information Subset Dataset Classification - Category Name Health Integration