WS/T 500.38-2016 in English

This standard establishes the structure and content requirements for the electronic medical record sharing document specifically for routine progress notes in inpatient records. It defines the data elements, formatting guidelines, and encoding rules necessary to ensure consistency and interoperability across healthcare information systems. The document provides a standardized framework for capturing and exchanging clinical information, supporting efficient data management and communication between healthcare providers. It includes specifications for the organization of data, the use of controlled terminologies, and the representation of clinical observations and documentation. The standard also outlines the necessary metadata and reference information to facilitate accurate interpretation and integration of the shared records within different clinical environments.