WS/T 500.6-2016Specification for sharing document of electronic medical record - Part 6: Examination report (English PDF)

Foreword

WS/T 500 "electronic medical record sharing document specification" is divided into the following fifty-three parts.

- Part 1. Summary of medical records;

- Part 2. door (emergency) medical records;

- Part 3. emergency medical records;

- Part 4. Western medicine prescription;

- Part 5. Traditional Chinese medicine prescription;

- Part 6. Inspection report;

- Part 7. Inspection report;

- Part 8. Treatment records;

- Part 9. General surgical records;

- Part 10. Anesthesia visit records;

- Part 11. Anesthesia records;

- Part 12. Record of visits after anesthesia;

- Part 13. Blood transfusion records;

- Part 14. Records to be produced;

- Part 15. Vaginal childbirth records;

- Part 16. cesarean section records;

- Part 17. General Nursing Records;

- Part 18. Critical (critical) care record;

- Part 19. Surgical care records;

- Part 20. Measurement of vital signs;

- Part 21. entry and exit records;

- Part 22. High value consumables use records;

- Part 23. admission assessment;

- Part 24. Nursing plan;

- Part 25. Discharge assessment and guidance;

- Part 26. Surgery informed consent;

- Part 27. Informed consent for anesthesia;

- Part 28. Consent to blood transfusion therapy;

- Part 29. Special inspection and special treatment consent;

- Part 30. Dangerous (heavy) notice;

- Part 31. Other informed consent;

- Part 32. Hospital medical case home page;

- Part 33. Chinese medicine hospitalization case home;

- Part 34. Admission records;

- Part 35. Departure records within 24 hours;

- Part 36. Death records within 24 hours;

- Part 37. Inpatient course records First course record;

- Part 38. Daily course of hospitalization Record of daily course of disease;

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

- Part 40. Inpatient course record of difficult cases;

- Part 41. Record of hospitalized course records;

- Part 42. Inpatient course records Transit records;

- Part 43. Summary of hospitalization course records;

- Part 44. Inpatient course records of rescue records;

- Part 45. Inpatient course records Consultation records;

- Part 46. Preoperative summary of hospitalized course records;

- Part 47. Preoperative discussion of hospitalized course records;

- Part 48. Record of the first course of disease after hospitalization;

- Part 49. Inpatient course records Discharge records;

- Part 50. Inpatient course record of death records;

- Part 51. Inpatient course records Record of death cases;

- Part 52. Hospital admissions;

Part 53. Discharging Summary.

This section is part 6 of WS/T 500.

This part is drafted in accordance with the rules given in GB/T 1.1-2009.

This part of the drafting unit. Zhejiang Digital Medical Technology Research Institute, the Chinese People's Liberation Army General Hospital, Huazhong University of Science and Technology Tongji Medical College.

1 Scope

This part of WS/T 500 specifies a document template for inspection reports and a series of constraints on document headers and document bodies.

This section applies to the development and application of standardized inspection, transmission, storage, shared exchange and information systems for inspection reports in electronic medical records.

2 Normative reference documents

The following documents are indispensable for the application of this document. For dated references, the only dated edition applies to this article the latest version (including all modifications) applies to this document.

Code for documentation of health information sharing in WS/T 482

3 Terms and abbreviations

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

4 Document content composition

The contents of the business document are shown in Table 1. See Appendix A for a sample document.

Table 1 Business document content composition

Document composition information module base 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 Associated Activity Information 0. * document body Diagnostic Records Section 1.1 Complaints Section 1.1 Symptom Section 1.1 Surgical Operation Section 0.1 Physical examination section 1.1 Other Disposal Section 0.1 Inspection Report Section 1.1