T/CHIA 46.7-2023 Chronic Hepatitis B Specialized Electronic Medical Record Basic Dataset Part 7: Nursing Procedure Recordings
T/CHIA 46.7-2023 Chronic Hepatitis B Specialized Electronic Medical Record Basic Dataset Part 7: Nursing Procedure Recordings
Basic Information
Scope
Main technical content: This document is drafted in accordance with the provisions of GB/T 1.1—2020. The "Basic Data Set for Electronic Medical Records of Chronic Hepatitis B Specialty" is divided into 13 parts: — Part 1: Patient basic information — Part 2: Outpatient (emergency) medical records — Part 3: Outpatient (emergency) prescriptions — Part 4: Examination records — Part 5: Laboratory test records — Part 6: Specialty inpatient case summary — Part 7: Nursing operation records — Part 8: Nursing assessment and plan — Part 9: Admission records — Part 10: Discharge records — Part 11: Inpatient medical orders — Part 12: Referral (hospital) records — Part 13: Medical institution information This document is Part 7 of T/CHIA 46. It was proposed by Mengchao Liver and Biliary Hospital of Fujian Medical University and is under the jurisdiction of the Chinese Society of Health Informatics and Big Data in Healthcare.