WS/T 483.6-2016Specification for sharing document of residents health record. Part 6: Prenatal follow-up visit service (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 6 of WS/T 483.

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

This section is drafted. Chinese People's Liberation Army General Hospital, China Center for Disease Control and Prevention Maternal and Child Health Center, Huazhong University of Science and Technology School of Economics

1 Scope

This part of WS/T 483 specifies the documentation template for prenatal follow-up service records, the requirements of the document architecture, and the documentation and documentation Body a series of constraints.

This section is suitable for prenatal follow-up service record 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.

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

Table 1 document content structure

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 Vital Signs chapter 1.1 Major Health Issues Chapter 1.1 Prenatal Care Chapter 1.1 Laboratory tests Section 1.1 Auxiliary Inspection Section 0.1 Health Assessment Chapter 1.1 Health guide section 0.1 Referral advice Chapter 0. * the next follow up is to arrange chapter 1.1