WS 445.8-2014Basic dataset of electronic medical record. Part 8: Nursing valuation and plan (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 eighth part of WS 445.

This section mainly drafted by. Shengjing Hospital Affiliated to China Medical University, Fourth Military Medical University People's Liberation Army Health Information Research the Ministry of Health Statistics Information Center.

1 Scope

This part of WS 445 specifies dataset metadata attributes and data element attributes for the Nursing Assessment and Planning Basic Data Set.

This section applies to guide the evaluation and planning of basic information collection, 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 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 4658-2006 Health Information Data Element Value Range Code Part 5. Health Risk Factors Health information data - Element code area code - Part 11. Medical assessment 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-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.