WS/T 483.17-2016Specification for sharing document of residents health record. Part 17: Outpatient medical summary (English PDF)

Foreword

WS/T 483 "health file sharing document specification" is divided into the following twenty parts.

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

--- Part 2. Birth medical certificate;

--- Part 3. Newborn family visit;

--- Part 4. child health examination;

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

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

--- Part 7. postpartum visit;

--- Part 8. Postpartum 42 days health check;

--- Part 9. Vaccination reports;

--- Part 10. Infectious Diseases Report;

--- Part 11. Medical proof of death;

--- Part 12. Hypertensive patients follow-up services;

--- Part 13. Type 2 diabetes patients follow-up service;

--- Part 14. Registration of personal information of patients with severe mental illness;

--- Part 15. follow-up services for patients with severe mental illness;

--- Part 16. Adult health examination;

--- Part 17. Clinic summary;

--- Part 18. Hospital summary;

--- Part 19. consultation records;

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

This section is Part 17 of the WS/T 483.

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

This section was drafted. Fourth Military Medical University Institute of Health Information, Fourth Military Medical University Xijing Hospital, Huazhong University of Science and Technology Tongji Medical College

1 Scope

This part of WS/T 483 specifies the document templates for outpatient summaries, the requirements for the document architecture, and the relationship between the document header and the document body Column constraint.

This section is suitable for out-patient summary document application.

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 classification and code Part 2. Marital status code WS/T 482 Health Information Sharing Document Preparation Specification

3 Terms and abbreviations

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

4 Document content structure

The contents of the document are shown in Table 1, and for the document examples, see Appendix A.

Table 1 outpatient summary document content composition table

Document composition information module cardinality document header document Activity Class Information 1.1 Patient Information 1.1 Creator Information 1.1 Data entry information 0.1 document Manager Information 1.1 Related activities information 0. * document body Major Health Issues Chapter 1.1 Symptoms Chapter 1.1 Laboratory tests Section 1.1 Diagnostic record section 1.1