WS/T 500.53-2016Specification for sharing document of electronic medical record - Part 53: Discharged brief (English PDF)

Foreword

The WS/T 500 EHR Sharing Document Specification is divided into the following 53 sections.

--- Part 1. Medical records summary;

--- Part 2. Door (urgent) medical records;

--- Part 3. Emergency medical records;

--- Part 4. Western prescriptions;

--- Part 5. Traditional Chinese medicine prescriptions;

--- Part 6. Inspection Report;

--- Part 7. Inspection report;

--- Part 8. Treatment records;

--- Part 9. General surgical records;

--- Part 10. Anesthesia preoperative visit records;

--- Part 11. Anesthetic records;

--- Part 12. Visits recorded after anesthesia;

--- Part 13. Transfusion records;

--- Part 14. To be produced records;

--- Part 15. Vaginal delivery records;

--- Part 16. Cesarean section records;

--- Part 17. General nursing records;

--- Part 18. Sick (critically ill) nursing records;

--- Part 19. Surgical care records;

--- Part 20. Vital signs measurement records;

--- Part 21. Access records;

--- Part 22. High-value supplies use records;

--- Part 23. Admission assessment;

--- Part 24. Nursing plan;

--- Part 25. Discharge assessment and guidance;

--- Part 26. Surgical informed consent;

--- Part 27. Anesthetic informed consent;

--- Part 28. Consent for the treatment of blood transfusions;

--- Part 29. Special inspection and special treatment consent;

--- Part 30. Dying (heavy) notice;

--- Part 31. Other forms of informed consent;

--- Part 32. Inpatient medical records home page;

--- Part 33. Chinese medical records Home;

--- Part 34. Admission records;

--- Part 35. Discharge record within 24 hours;

--- Part 36. 24 hours admission record of death;

--- Part 37. Inpatient course records the first course record;

--- Part 38. In-hospital record of routine course of disease records;

--- Part 39. Inpatient records of superior physician rounds record;

--- Part 40. In-patient records of difficult cases history records;

--- Part 41. Inpatient records of the transfer records;

--- Part 42. Records of hospitalization course transfer records;

--- Part 43. In-patient record summary stage;

--- Part 44. Inpatient records of treatment records;

--- Part 45. Inpatient records of the consultation records;

--- Part 46. In-hospital record of preoperative summary;

--- Part 47. In-hospital record of preoperative discussion;

--- Part 48. In-hospital record of the first course of disease records;

--- Part 49. Inpatient records of hospital records of discharge;

--- Part 50. In-hospital records of death records;

--- Part 51. Inpatient records of death records discussed;

--- Part 52. Inpatient orders;

--- Part 53. Discharge summary.

This section is Part 53 of the WS/T 500.

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

This section is drafted unit. West China Hospital of Sichuan University, Chinese People's Liberation Army General Hospital, Wuxi Chinese Medicine Hospital, Huazhong University of Science and Technology Tongji Medical school.

1 Scope

This part of WS/T 500 specifies the document templates for the discharge summary and a series of constraints on the document header and document body.

This section applies to electronic records in the discharge summary of the norms collection, transmission, storage, sharing exchange and development and application of information systems.

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 contents of the business documents are shown in Table 1, and the examples of documents are shown in Appendix A.

Table 1 discharge summary 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 Major Health Issues Chapter 1.1 Admission diagnosis section 1.1 Discharge diagnosis section 1.1 Surgery Chapter 1.1 Treatment Planning Section 0.1 Inpatient Procedures Section 1.1 Medical order section 1.1 Laboratory tests Section 1.1