T/CHIA 46.4-2023 Chronic Hepatitis B Specialty Electronic Medical Record Basic Dataset Part 4: Examination Record
T/CHIA 46.4-2023 Chronic Hepatitis B Specialty Electronic Medical Record Basic Dataset Part 4: Examination Record
Basic Information
Scope
Main technical content: This document was drafted in accordance with the provisions set forth in GB/T 1.1—2020. The "Basic Data Set for Electronic Medical Records in Chronic Hepatitis B Specialty Clinics" 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 planning — 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 the fourth part of T/CHIA 46. It was proposed by Mengchao Liver and Bile Hospital of Fujian Medical University and is coordinated by the Chinese Society of Health Informatics and Big Data in Healthcare.