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WS/T 483.1-2016Specification for sharing document of residents health record. Part 1: Personal basic health information registration (English PDF)

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Issued by

National Health and Family Planning Commission of the People's Republic of China

Level / Type

National · Recommended

Issue date

July 12, 2016

Implementation date

December 15, 2016

Scope

WS/T 483.1-2016 (Specification for sharing document of residents health record. Part 1: Personal basic health information registration) is available as an English-translated PDF.

WS/T 483.1-2016 — This part of WS/T 483 specifies the document template for personal basic health information registration, the requirements for the document structure, and the A series of constraints on the body of the document.

This part is suitable for the application of personal basic health information registration documents.

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Document preview — WS/T 483.1-2016

National Standard of the People's Republic of China

ICS: 11.020
Classification: C 07

Issued by: National Health and Family Planning Commission of the People's Republic of China

Preface
1 Scope
2 Normative references
3 Terms and abbreviations
4 Document content structure
5 Document header specification
5.1 Document Activity Class Specification
5.2 Participant class specification
5.3 Specification for related activities
6 Document body specification
6.1 Document body chapter structure
6.2 Laboratory Inspection Chapter
6.3 Cost section
6.4 Allergy History Chapter
6.5 Occupational Exposure History Chapter
6.6 Chapter 10 of Past History
6.7 Chapter 13 of Family History
6.8 Chapter 14 of Genetic History
6.9 Disability History Chapter
6.10 Chapter 16 of Living Environment
Appendix A (informative appendix) Example of personal basic health information registration document

Foreword

WS/T 483 "Health File Sharing Document Specification" is divided into the following 20 parts.

---Part 1: Personal basic health information registration;

---Part 2: Birth medical certificate;

---Part 3: Family visits for newborns;

---Part 4: Children's health examination;

---Part 5: First prenatal follow-up service;

---Part 6: Prenatal follow-up service;

---Part 7: Postpartum visit;

---Part 8: Health check on 42 days after delivery;

---Part 9: Vaccination report;

---Part 10: Infectious Disease Report;

---Part 11: Death medical certificate;

---Part 12: Follow-up service for patients with hypertension;

---Part 13: Follow-up service for patients with type 2 diabetes;

---Part 14: Personal information registration of patients with severe mental illness;

---Part 15: Follow-up service for patients with severe mental illness;

---Part 16: Adult health examination;

---Part 17: Outpatient summary;

---Part 18: Hospitalization Summary;

---Part 19: Consultation records;

---Part 20: Referral (hospital) records.

This part is Part 1 of WS/T 483.

This section was drafted in accordance with the rules given in GB/T 1.1-2009.

Drafting organizations of this section. Institute of Health Information, Fourth Military Medical University, Tongji Medical College of Huazhong University of Science and Technology, Shanghai Center for Disease Control and Prevention National Health and Family Planning Commission Statistical Information Center.

1 Scope

This part of WS/T 483 specifies the document template for personal basic health information registration, the requirements for the document structure, and the A series of constraints on the body of the document.

This part is suitable for the application of personal basic health information registration documents.

2 Normative references

The following documents are indispensable for the application of this document. For dated reference documents, only the dated version applies to this article Pieces. For undated references, the latest version (including all amendments) applies to this document.

GB/T 2261.1-2003 Classification and codes of basic personal information Part 1: Gender codes of persons GB/T 221.2-2003 Classification and codes of basic personal information Part 2: Marital status codes GB 3304-1991 Roman alphabet spelling and codes for the names of various ethnic groups in China GB/T 4658-2006 academic code GB/T 6565-2015 Occupation Classification and Code WS/T 482 Health Information Sharing Document Preparation Specification

3 Terms and abbreviations

The terms and abbreviations defined in WS/T 482 apply to this document.

4 Document content structure

The composition of the document content is shown in Table 1, and the document example is shown in Appendix A.

5 Document header specification

5.1 Document Activity Class Specification

The composition of document activity elements and their correspondence with data elements are shown in Table 2.

5.2 Participant class specification

The composition of participant class elements and the corresponding relationship with data elements are shown in Table 3.

5.3 Specifications for related activities

The specification element composition of the associated activity class and the corresponding relationship with the data element are shown in Table 4.

6 Document body specification

6.1 Document body chapter structure

The chapter structure of the document body is shown in Table 5.

6.2 Laboratory inspection chapter

6.2.1 The composition of the laboratory inspection chapter entries the composition of items in the laboratory inspection chapter is shown in Table 6.

6.3 Cost section

6.3.1 The composition of cost chapter entries See Table 8 for the composition of items in the cost chapter.

6.3.2 Element composition of cost chapter

The element composition of the cost chapter is shown in Table 9.

6.4 Allergy history chapter

6.4.1 The composition of allergy history chapter entries the composition of allergy history chapter entries is shown in Table 10.

Table 10 Composition of allergy history chapter entries

Item name cardinality constraint description Allergy entry 0.. O describes allergy-related activities, it focuses on allergy-related records

6.4.2 Elemental composition of allergy history chapter

The element composition of the allergy history chapter is shown in Table 11.

6.5.2 Elemental composition of the chapter on occupational exposure history

See Table 13 for the element composition of the chapter on occupational exposure history.

6.6 Chapters of past history

6.6.1 The composition of past history chapter entries the composition of the chapters of past history is shown in Table 14.

6.7.2 Elemental composition of family history chapters

The element composition of the family history chapter is shown in Table 17.

6.8 Chapter of genetic history

6.8.1 The composition of the chapter entries of genetic history the composition of entries in the chapter of genetic history is shown in Table 18.

Table 18 The composition of the chapter entries of the genetic history

Item name cardinality constraint description Genetic history items 1.. R describes the activities related to the genetic history, and it focuses on the patient's genetic history records

6.8.2 Element composition of the chapter of genetic history

The element composition of the genetic history chapter is shown in Table 19.

6.9.2 Element composition of the chapter on the history of disability

The element composition of the chapter on the history of disability is shown in Table 21.

6.10 Living environment chapter

6.10.1 The composition of the chapter entries of the living environment See Table 22 for the composition of entries in the living environment chapter.

6.10.2 Element composition of the chapter on living environment

See Table 23 for the element composition of the living environment chapter.

......
This preview omits tables, figures, formulas and parts of the technical clauses. The complete document — 21 pages — is available in the English PDF.

Referenced standards

Normative references

GB/T 221.2-2003 · GB 3304-1991

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