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WS/T 483.4-2016Specification for sharing document of residents health record. Part 4: Children physical examination (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 483.4-2016 (Specification for sharing document of residents health record. Part 4: Children physical examination) is available as an English-translated PDF.

WS/T 483.4-2016 — This part of WS 483/T stipulates the requirements for the child health examination document template, document structure, and the document header and body.

Series constraints. This part is suitable for the application of children's health examination documents.

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Document preview — WS/T 483.4-2016

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

Contents

  • 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 Vital Signs Chapter
  • 6.3 General appearance chapter
  • 6.4 Skin Chapter
  • 6.5 Head Chapter
  • 6.6 Neck Chapter
  • 6.7 Eye Chapter
  • 6.8 Ear Chapter
  • 6.9 Mouth, Throat and Teeth Chapter
  • 6.10 Heart Chapter
  • 6.11 Respiratory System Chapter
  • 6.12 Abdomen Chapter
  • 6.13 Limbs Chapter
  • 6.14 Spine Chapter
  • 6.15 Genitals Chapter
  • 6.16 Chapter 25 Rectal
  • 6.17 Chapter 26 of Child Health History
  • 6.18 Laboratory Inspection Chapter
  • 6.19 Medication Chapter
  • 6.20 Health Assessment Chapter
  • 6.21 Health Guidance Chapter
  • 6.22 Referral Recommendation Section
  • 6.23 Next follow-up arrangement Chapter
  • Appendix A (informative appendix) Example of child health examination 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 4 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. National Health and Family Planning Commission Statistical Information Center, Tongji Medical College of Huazhong University of Science and Technology, Chinese Diseases Prevention and Control Center Maternal and Child Health Center.

1 Scope

This part of WS 483/T stipulates the requirements for the child health examination document template, document structure, and the document header and body.

Series constraints.

This part is suitable for the application of children's health examination 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.

WS 482/T Health Information Sharing Document Preparation Specification

3 Terms and abbreviations

The terms and abbreviations defined by WS 482/T 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.

6.2 Vital Signs Chapter

6.2.1 Composition of vital signs chapter entries

See Table 6 for the composition of entries in the vital signs chapter.

6.3.2 General appearance chapter element composition

The element composition of the general appearance section is shown in Table 9.

6.5 Head Chapter

6.5.1 The composition of head chapter entries the composition of head chapter entries is shown in Table 12.

6.6 The neck section

6.6.1 The composition of neck chapter entries the composition of the neck chapter entries is shown in Table 14.

6.7 Eye chapter

6.7.1 The composition of eye chapter entries the composition of eye chapter entries is shown in Table 16.

6.8 Ear chapter

6.8.1 The composition of ear chapter entries the composition of the entries in the anti-ear chapter is shown in Table 18.

......
This preview omits tables, figures, formulas and parts of the technical clauses. The complete document — 37 pages — is available in the English PDF.

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