WS 445.9-2014Basic dataset of electronic medical record. Part 9: Informing information (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 9 of the WS 445.

This part mainly drafted by. Institute of Health Information Fourth Military Medical University, Guangdong Provincial Hospital of Traditional Chinese Medicine, Ministry of Health statistics information Center.

1 Scope

This part of WS 445 specifies the data set metadata attributes and data element attributes of the informational informed basic data set.

This section applies to the informed of the 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 GB/T 4761-2008 family relationship code 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.

Table 1 Dataset metadata attributes

Metadata Subset Metadata Item Metadata value Identification information Subset the data set name is informed about the basic data set of the information Dataset identifier HDSD00.10_V1.0 Data Collector - Name of Organization National Standards Committee of Health Standards Committee of Information Standards Key words risk, surgery, special examination and treatment, blood transfusion, critically ill (heavy) notification Data set language Chinese Data set classification - category name health synthesis