WS/T 500.40-2016Specification for sharing document of electronic medical record - Part 40: Inpatient progress note - Discussion of intractable case record (English PDF)

Foreword

WS/T 500 "Specifications for Shared Documents of Electronic Medical Records" is divided into the following 53 parts.

---Part 1: Summary of medical records;

---Part 2: Outpatient (emergency) medical records;

---Part 3: Emergency Observation Medical Records;

---Part 4: Western medicine prescription;

---Part 5: Chinese medicine prescription;

---Part 6: Inspection report;

---Part 7: Inspection report;

---Part 8: Treatment records;

---Part 9: General operation records;

---Part 10: Pre-anesthesia visit records;

---Part 11: Anesthesia records;

---Part 12: Post-anaesthesia visit records;

---Part 13: Blood transfusion records;

---Part 14: Pending production records;

---Part 15: Records of vaginal delivery;

---Part 16: Cesarean section records;

---Part 17: General nursing records;

---Part 18: Seriously ill (critically ill) nursing records;

---Part 19: Surgical nursing records;

---Part 20.vital signs measurement records;

---Part 21: Entry and exit records;

---Part 22: Use records of high-value consumables;

---Part 23: Admission assessment;

---Part 24: Nursing Plan;

---Part 25: Discharge assessment and guidance;

---Part 26: Informed Consent Form for Surgery;

---Part 27: Anesthesia informed consent;

---Part 28: Consent Form for Blood Transfusion Treatment;

---Part 29: Special examination and special treatment consent form;

---Part 30: Notice of Critical Illness (Severe);

---Part 31: Other informed consent forms;

---Part 32: First page of hospitalized medical records;

---Part 33: Homepage of Chinese Medicine Hospitalized Medical Record;

---Part 34: Admission records;

---Part 35: Records of admission and discharge within 24 hours;

---Part 36: Death records of hospital admission within 24 hours;

---Part 37: Record of the course of hospitalization for the first time;

---Part 38: Inpatient course records and daily course records;

---Part 39: Records of hospitalization course records of superior physicians' rounds;

---Part 40: Inpatient course record and difficult case discussion record;

---Part 41: Inpatient course record and shift record;

---Part 42: Inpatient course records and transfer records;

---Part 43: Summary of the stage of hospitalization record;

---Part 44: Records of hospitalization and rescue records;

---Part 45: Inpatient course record and consultation record;

---Part 46: Preoperative summary of hospitalization record;

---Part 47: Preoperative discussion of hospitalization record;

---Part 48: Record of the first course of illness after the hospitalization;

---Part 49: Hospitalization and Discharge Records;

---Part 50: Inpatient course record and death record;

---Part 51: Inpatient course record and death case discussion record;

---Part 52: Hospital orders;

---Part 53: Summary of discharge.

This part is part 40 of WS/T 500.

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

Drafting organizations of this section. Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, National Health and Family Planning Commission Statistical Information Center, Wuxi City Chinese Medicine Hospital.

1 Scope

This part of WS/T 500 specifies the document template for difficult case discussion records and a series of constraints on the document header and body.

This part is applicable to the standardized collection, transmission, storage, sharing and exchange of discussion records of difficult cases in electronic medical records and the information system Develop applications.

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/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 content composition of business documents is shown in Table 1, and examples of documents are shown in Appendix A.

5 Document header specification

6 Document body specification