IHEActCode Vocabulary/zh

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IHE行动代码词表(IHEActCode Vocabulary)

CCD   ASTM/HL7 Continuity of Care Document ASTM/HL7 连续性照护文档
CCR   ASTM CCR Implementation Guide ASTM CCR 实施指南

IHE行动代码词表(IHEActCode Vocabulary)是由HL7行动代码词表(HL7 ActCode vocabulary)目前并不支持的临床行动(clinical acts)代码所构成的一部小型词表。这部词表的根节点名称空间(OID)为1.3.5.1.4.1.19376.1.5.3.2。这些词表术语基于上述CCR和CCD标准之中所采用的词表和概念。

代码 代码中文名称 英文描述 中文描述
COMMENT 注释 This is the act of commenting on another act. 这是就另一行动加以评价或注解的行动。
PINSTRUCT 提供用药说明 This is the act of providing instructions to a patient regarding the use of medication. 这是针对药物的使用向某位病人提供使用说明的行动。
FINSTRUCT 提供用药医嘱执行说明 This is the act of providing instructions to the supplier regarding the fulfillment of the medication order. 这是针对用药医嘱的执行向提供者说明的行动。
IMMUNIZ 免疫接种 The act of immunization of a patient using a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances. 采用某部指定词表所标识的特定物质或某类物质对某位病人进行免疫接种的行动。对于这条词表术语的使用,需要在采用某种经过标识的物质或某类物质的同时,还要配合使用如下所述的限定成分(qualifier)SUBSTANCE或者SUBSTCLASS。
DRUG 药物治疗 The act of treating a patient with a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances. 采用某部指定词表所标识的特定物质或某类物质对某位病人进行处治的行动。对于这条词表术语的使用,需要在采用某种经过标识的物质或某类物质的同时,还要配合使用如下所述的限定成分(qualifier)SUBSTANCE或者SUBSTCLASS。
INTOL 关于物质不耐的观察 An observation that a patient is somehow intollerant of (e.g., allergic to) a particular substance or class of substances using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances. 某位病人对某部指定词表所标识的特定物质或某类物质存在某种程度的不耐(比如,发生变态反应或者说过敏)。对于这条词表术语的使用,需要在采用某种经过标识的物质或某类物质的同时,还要配合使用如下所述的限定成分(qualifier)SUBSTANCE或者SUBSTCLASS。
SUBSTANCE 物质 A qualifier that identifies the substance used to treat a patient in an immunization or drug treatment act. The substance is expected to be identified using a vocabulary such as RxNORM, SNOMED CT or other similar vocabulary and should be specific enough to identify the ingredients of the substance used. 一个限定成分,其标识的是在某个免疫接种或药物治疗行动之中用于治疗某位病人的那种物质类。该物质预期采用RxNORM、SNOMED CT或其他类似词表之类的某部词表来加以标识;而且,该物质还应当足够特异,足以标识所用物质的那些成分。
SUBSTCLASS 物质类 A qualifier that identifies the class of substance used to treat a patient in an immunization or drug treatment act. The class of substances is expected to be identified using a vocabulary such as NDF-RT, SNOMED CT or other similar vocabulary, and should be broad enough to classify substances by mechanism of action (e.g., Beta Blocker), intended effect (Dieuretic, antibiotic) or ... 一个限定成分,其标识的是在某个免疫接种或药物治疗行动之中用于治疗某位病人的那个物质类。该物质预期采用DF-RT、SNOMED CT或其他类似词表之类的某部词表来加以标识;而且,该物质应当足够宽泛,足以按照作用机理(比如,β受体阻滞剂)、预期效果(比如,利尿剂、抗生素)等等对有关物质加以分类。


公开征求意见 关于上述的SUBSTCLASS还需要别的什么吗?