WS 445.6-2014Basic dataset of electronic medical record. Part 6: Delivery record of therapy and treatment (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 sixth part of WS 445.

This part mainly drafted by. Beijing Maternal and Child Health Hospital, National Maternal and Child Health Center, Chinese People's Liberation Army General Hospital, Ministry of Health statistics letter Interest Center.

1 Scope

This part of WS 445 specifies the dataset metadata attributes and data element attributes for midwifery record base data sets.

This section applies to guide the midwifery record 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 Health Information Data Element Value Range Codes Part 4. Health History Health information data - Element code area code - Part 10. Medical diagnosis 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

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 Dataset Name Midwifery Record base dataset Data Set Identifier HDSD00.07_V1.0 Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards Keywords midwifery records Data set language Chinese Data set classification - category name health synthesis