T/CHIA 53.5-2024 Electronic medical record dataset standard for myocardial infarction, Part 5: Examination records
T/CHIA 53.5-2024 Electronic medical record dataset standard for myocardial infarction, Part 5: Examination records
Basic Information
Scope
Main technical content: This standard is drafted in accordance with the provisions of GB/T 1.1-2020 "Guidelines for Standardization Work - Part 1: Structure and Drafting Rules for Standardization Documents". This standard is the fifth part of T/CHIA 53-2024, "Standard for Electronic Medical Record Data Set of Myocardial Infarction". It is divided into the following 14 parts: ----- Part 1: Patient Basic Information ----- Part 2: Outpatient/Emergency Medical Records ----- Part 3: Outpatient/Emergency Prescriptions ----- Part 4: Emergency Observation Medical Records ----- Part 5: Examination Records ----- Part 6: Laboratory Test Records ----- Part 7: Nursing Operation Records ----- Part 8: Nursing Assessment and Planning ----- Part 9: Hospitalization Case First Page ----- Part 10: Admission Records ----- Part 11: Discharge Summary ----- Part 12: Hospital Medical Orders ----- Part 13: Referral (Hospital) Records ----- Part 14: Medical Institution Information This standard was proposed by Xiangya Third Hospital of Central South University and is under the jurisdiction of the Chinese Society of Health Informatics and Big Data in Healthcare.