PCC TF-2/Header/zh

From IHE Wiki
Jump to: navigation, search

HIMSS and RSNA
Integrating the Healthcare Enterprise

IHEBandW.png

IHE Patient Care Coordination

Technical Framework
Volume II

Revision 3.0
2008-2009

Public Comment


IHE交易(IHE Transactions)

本节将详细定义各种IHE交易,规定所采用的那些标准以及所传输的那些信息。

IHE病人医疗护理服务协调绑定(IHE Patient Care Coordination Bindings)

This section describes how the payload used in a transaction of an IHE profile is related to and/or constrains the data elements sent or received in those transactions. This section is where any specific dependencies between the content and transaction are defined.

A content integration profile can define multiple bindings. Each binding should identify the transactions and content to which it applies.

The source for all required and optional attributes have been defined in the bindings below. Three tables describe the three main XDS object types: XDSDocumentEntry, XDSSubmissionSet, and XDSFolder. XDSSubmissionSet and XDSDocumentEntry are required. Use of XDSFolder is optional. These concepts are universal to XDS, XDR and XDM.

The columns of the following tables are:

  • <XXX> attribute – name of an XDS attribute, followed by any discussion of the binding detail.
  • Optional? - Indicates the required status of the XDS attribute, and is one of R, R2, or O (optional). This column is filled with the values specified in the XDS Profile as a convenience.
  • Source Type – Will contain one of the following values:
Source Type Description
SA Source document Attribute – value is copied directly from source document. The Source/Value column identifies where in the source document this attribute comes from. Specify the location in XPath when possible.
SAT Source document Attribute with Transformation – value is copied from source document and transformed. The Source/Value column identifies where in the source document this attribute comes from. Specify the location in XPath when possible. Extended Discussion column must not be empty and the transform must be defined in the extended discussion
FM Fixed (constant) by Mapping - for all source documents. Source/Value column contains the value to be used in all documents.
FAD Fixed by Affinity Domain – value configured into Affinity Domain, all documents will use this value.
CAD Coded in Affinity Domain – a list of acceptable codes are to be configured into Affinity Domain. The value for this attribute shall be taken from this list.
CADT Coded in Affinity Domain with Transform - a list of acceptable codes are to be configured into Affinity Domain. The value for this attribute shall be taken from this list.
n/a Not Applicable – may be used with an optionality R2 or O attribute to indicate it is not to be used.
DS Document Source – value comes from the Document Source actor. Use Source/Value column or Extended Discussion to give details.
O Other – Extended Discussion must be 'yes' and details given in an Extended Discussion.
  • Source/Value – This column indicates the source or the value used.

The following tables are intended to be summaries of the mapping and transforms. The accompanying sections labeled 'Extended Discussion' are to contain the details as necessary.

针对XDS、XDM和XDR的医疗文档绑定

这种绑定(binding)规定的是一种转换机制(transformation)。在存在来自其他来源的某份医疗文档以及信息的情况下,这种转换机制所产生的是来自XDS、XDM和XDR概貌的适当交易的XDS文档条目元数据(XDSDocumentEntry)要素。医疗文档(medical document,医疗文书)指的是存储在某个储存库(repository)之中并将在注册库(registry)之中加以引用的文档。其他信息来源包括文档来源角色(Document Source actor)的配置、共享域、地点或设施、本地协议、注册库/储存库之中的其他文档以及这份内容概貌。

在许多的情况下,CDA文档的创建针对的是特定共享域(affinity domain)之内不同的共享目的。在这些情况下,CDA的语境与共享域的语境并无两样;此时,必须运用下列映射关系。

在其他情况下,CDA文档可能是事先已经为内部用途而创建的,而后来又要加以共享。在这些情况下,CDA的语境并不一定会与共享域的语境相符。因此,下列映射关系此时并不一定会适用。

请注意如下表格之中所给出的具体细节。

XDS文档条目元数据

XDSDocumentEntry Attribute XDS文档条目属性中文名称 可选程度 来源类型 来源/取值 来源/取值中文说明
availabilityStatus 就绪状态 R DS  
authorInstitution 作者机构 R2 SAT

$inst <= /ClinicalDocument/author
/assignedAuthor
/representedOrganization

The authorInstitution can be formated
using the following XPath expression, where $inst in the expression below represents the representedOrganization.
concat($inst/name)

authorPerson 作者人员 R2 SAT

$person <= /ClinicalDocument/author

The author can be formatted using the following XPath expression, where $person in the expression below represents the author.
concat(
$person/id/@extension,"^",
$person/assignedPerson/name/family,"^",
$person/assignedPerson/name/given[1],"^",
$person/assignedPerson/name/given[2],"^",
$person/assignedPerson/name/suffix,"^",
$person/assignedPerson/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO")

authorRole 作者角色 R2 SAT This metadata element should be based on a mapping of the participation function defined in the CDA document to the set of author roles configured for the affinity domain. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:
/ClincicalDocument/author/
participationFunction
authorSpecialty 作者专业 R2 SAT This metadata element should be based on a mapping of the code associated with the assignedAuthor to detailed defined classification system for healthcare providers such configured in the affinitity domain. Possible classifications include those found in SNOMED-CT, or the HIPAA Healthcare Provider Taxonomy. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:
/ClinicalDocument/author/
assignedAuthor/code
classCode 类代码 R CADT Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code
classCodeDisplayName 类代码显示名称 R CADT DisplayName of the classCode derived. Derived from a mapping of /ClinicalDocument/code/@code to the appropriate Display Name based on the Type of Service. Must be Consitent with /ClinicalDocument/code/@code
confidentialityCode 密级代码 R CADT Derived from a mapping of /ClinicalDocument/confidentialityCode/@code to an Affinity Domain specified coded value and coding system. When using the BPPC profile, the confidentialyCode may also be obtained from the <authorization> element.


/ClinicalDocument/
confidentialityCode/@code
-AND/OR-
/ClinicalDocument/authorization/
consent[
templateId/@root=
'1.3.6.1.4.1.19376.1.5.3.1.2.5'
] /code/@code

comments 注释 O DS  
creationTime 创建时间 R SAT /ClinicalDocument/effectiveTime


Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.

entryUUID 条目UUID R DS  
eventCodeList 事件代码列表 O CADT These values express a collection of keywords that may be relevant to the consumer of the documents in the registry. They may come from anywhere in the CDA document, according to its purpose.
eventCodeDisplayNameList 事件代码显示名称列表 R
(if event
Code is valued)
CADT These are the display names for the collection of keywords described above.
formatCode 格式代码 R FM The format code for each PCC Document content profile is provided within the document specifications.
healthcareFacilityTypeCode 医疗保健设施类型代码 R CAD A fixed value assigned to the Document Source and configured form a set of Affinity Domain defined values. Must be concistent with /clinicalDocument/code
healthcareFacility
TypeCodeDisplay
Name
医疗保健设施类型代码显示名称 R CAD Must be concistent with /clinicalDocument/code
intendedRecipient (for XDR, XDM) 预定接收者 O SAT

$person <= /ClinicalDocument/intendedRecipient
and/or
$inst <= /ClinicalDocument/intendedRecipient/receivedOrganization

The intendedRecipient can be formated
using the following XPath expression, where $inst in the expression below represents the receivedOrganization and where $person in the expression below represents the intendedRecipient.
concat(
$person/id/@extension,"^",
$person/informationRecipient/name/family,"^",
$person/informationRecipient/name/given[1],"^",
$person/informationRecipient/name/given[2],"^",
$person/informationRecipient/name/suffix,"^",
$person/informationRecipient/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO",
"|"
$inst/name)

"^^^^^&",
$inst/id/@root, "&ISO", "^^^^", $inst/id/@extension)
-->

languageCode 语言代码 R SA /ClinicalDocument/languageCode
legalAuthenticator 法定审核者 O SAT $person <= /ClinicalDocument/
legalAuthenticator


The legalAuthenticator can be formatted using the following XPath expression, where $person in the expression below represents the legalAuthenticator.
concat(
$person/id/@extension,"^",
$person/assignedPerson/name/family,"^",
$person/assignedPerson/name/given[1],"^",
$person/assignedPerson/name/given[2],"^",
$person/assignedPerson/name/suffix,"^",
$person/assignedPerson/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO")

mimeType MIME类型 R FM text/xml
parentDocumentRelationship 父文档关系 R
(when applicable)
DS Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document.
The parentDocumentRelationship may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:
/ClinicalDocument/relatedDocument/@typeCode
parentDocumentId 父文档标识符 R
(when parent
Document
Relationship is present)
DS Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document.
The parentDocumentId may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:
$docID <= /ClinicalDocument/
relatedDocument/parentDocument/id


The parentDocumentId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier.
concat($docID/@root,"^", $docID/@extension)

patientId 病人标识符 R DS The XDS Affinity Domain patient ID can be mapped from the patientRole/id element using transactions from the ITI PIX or PDQ profiles. See sourcePatientId below. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate:


$patID <= /ClinicalDocument/recordTarget/
patientRole/id

practiceSettingCode 执业环境代码 R CAD This elements should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.
practiceSettingCodeDisplayName 执业环境代码显示名称 R CAD This element shall contain the display names associated with the codes described above.
serviceStartTime 服务开始时间 R2 SAT /ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value


Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.

serviceStopTime 服务停止时间 R2 SAT /ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value


Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.

sourcePatientId 来源病人标识符 R SAT $patID <= /ClinicalDocument/recordTarget/
patientRole/id


The patientId can be formatted using the following XPath expression, where $patID in the expression below represents the appropriate identifier.
concat($patID/@extension,"^^^&", $patID/@root, "&ISO")

sourcePatientInfo 来源病人信息 R SAT /ClinicalDocument/recordTarget/
patientRole


The sourcePatientInfo metadata element can be assembled from various components of the patientRole element in the clinical document.

title 标题 O SA /ClinicalDocument/title
typeCode 类型代码 R CADT /ClinicalDocument/code/@code


The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.

typeCodeDisplay
Name
类型代码显示名称 R CADT /ClinicalDocument/code/@displayName
uniqueId 唯一标识符 R SAT $docID <= /ClinicalDocument/id


The uniqueId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier.
concat($docID/@root,"^", $docID/@extension)

XDS提交集元数据

The submission set metadata is as defined for XDS, and is not necessarily affected by the content of the clinical document. Metadata values in an XDSSubmissionSet with names identical to those in the XDSDocumentEntry may be inherited from XDSDocumentEntry metadata, but this is left to affinity domain policy and/or application configuration.

XDS提交集的使用

This content format uses the XDS Submission Set to create a package of information to send from one provider to another. All documents referenced by the Medical Summary in this Package must be in the submission set.

XDS文件夹的使用

No specific requirements identified.

配置

IHE Content Profiles using this binding require that Content Creators and Content Consumers be configurable with institution and other specific attributes or parameters. Implementers should be aware of these requirements to make such attributes easily configurable. There shall be a mechanism for the publishing and distribution of style sheets used to view clinical documents.

来自其他领域的扩展(Extensions from other Domains)

扫描型文档(Scanned Documents)(XDS-SD)

XDS-SD is a CDA R2 document and thus conforms to the XDS Metadata requirements in the PCC-TF, volume 2, Section 5 unless otherwise specified below.

XDS文档条目(XDSDocumentEntry)

XDS-SD leverages the XDS DocumentEntry Metadata requirements in the PCC-TF, volume 2, Section 5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below

XDS文档条目格式代码(XDSDocumentEntry.formatCode)

The XDSDocumentEntry.formatCode shall be urn:ihe:iti:xds-sd:pdf:2008 when the document is scanned pdf and urn:ihe:iti:xds-sd:text:2008 when the document is scanned text. The formatCode codeSystem shall be 1.3.6.1.4.1.19376.1.2.3.

XDS文档条目唯一标识符(XDSDocumentEntry.uniqueId)

This value shall be the ClinicalDocument/id in the HL7 CDA R2 header. The root attribute is required, and the extension attribute is optional. In accordance with the XDS.a profile, total length is limited to 128 characters; for XDS.b the limit is 256 characters. Additionally see PCC-TF, volume 2, Section 5.1.1.1.1 or PCC_TF-2/Bindings for further content specification.

XDS-SD文档实例的关联(Relating instances of XDS-SD documents)

In general, most instances of XDS-SD will not have parent documents. It is possible, however, in some specific use cases that instances of XDS-SD documents are related. For example, for a particular document it may be the case that both the PDF scanned content and somewhat equivalent plaintext need to be wrapped and submitted. Each document would correspond to separate XDSDocumentEntries linked via an XFRM Association that indicates one document is a transform of the other. These can be submitted in a single submission set, or in separate ones. Other specific examples may exist and this profile does not preclude the notion of a parent document for these cases.

XDS提交集(XDSSubmissionSet)

No additional constraints. Particular to this profile, a legitimate use of submission sets would be to maintain a logical grouping of multiple XDS-SD documents. We encourage such usage. For more information, see PCC-TF-2 Section 5.1.1.1.2 or PCC_TF-2/Bindings.

XDS文件夹(XDSFolder)

No additional requirements. For more information, see PCC-TF-2 Section 5.1.1.1.3 or PCC_TF-2/Bindings.

基本病人隐私知情同意书(Basic Patient Privacy Consents,BPPC)

实验室检验报告(Laboratory Reports)(XD-LAB)

XD-Lab is a CDA R2 document and thus conforms to the XDS Metadata requirements in the PCC-TF, volume 2, Section 5 unless otherwise specified below.

XDS文档条目(XDSDocumentEntry)

XD-Lab leverages the XDS DocumentEntry Metadata requirements in the PCC-TF, volume 2, Section 5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below

XDS文档条目事件代码列表(XDSDocumentEntry.eventCodeList)

XD-Lab documents further constrain the the XDSDocumentEntry.eventCodeList to the following.

XDSDocumentEntry
Attribute Optional? Source Type Source/ Value
eventCodeList R2 SAT ClinicalDocument / component / structuredBody / component / section / entry / act / entryRelationship / organizer (templateId="1.3.6.1.4.1.19376.1.3.1.1")/ component / observation(templateId="1.3.6.1.4.1.19376.1.3.1.1.1")/code

AND

ClinicalDocument / component / structuredBody / component / section / entry / act / subject / code

If the document has Reportable Condition, then this code shall be among those listed in the eventCodeList. Additionally, if the document contains information about a Non-Human Subject, then the code that indicates what this subject is shall be among those listed in the eventCodeList. Thus, this attribute has been enhanced from the XDS profile from O to R2.

XDS文档条目格式代码(XDSDocumentEntry.formatCode)

XDS文档条目格式代码XDSDocumentEntry.formatCode必须为 urn:ihe:lab:xd-lab:2008 。格式代码formatCode的编码系统codeSystem必须为1.3.6.1.4.1.19376.1.2.3。

XDS提交集(XDSSubmissionSet)

无额外的约束。详情请参见PCC-TF-2 第5.1.1.1.2小节 或者 PCC_TF-2/Bindings/zh.

XDS文件夹(XDSFolder)

无额外的约束。详情请参见PCC-TF-2 第5.1.1.1.3小节 或者 PCC_TF-2/Bindings/zh

名称空间与词表

本节列出的是IHE PCC 技术框架(IHE PCC Technical Framework)所定义或引用的那些名称空间和标识符,以及本页面当中所定义的那些词表。

本文档之中引用了下列词表。在下列网址可找到内容更为广泛的已注册的词表: http://www.hl7.org/oid/.

所采用的词表
代码系统(codeSystem) 代码系统名称(codeSystemName) 描述
1.3.6.1.4.1.19376.1.5.3.1 IHE PCC模板标识符(IHE PCC Template Identifiers) 这是所有IHE PCC模板(IHE PCC Templates)的根节点OID(root OID)。在CDA 2.0版内容模块(CDA Release 2.0 Content Modules)之中可找到PCC模板列表。
1.3.6.1.4.1.19376.1.5.3.2 IHEActCode 参见下文的IHE行动代码词表(IHEActCode Vocabulary)
1.3.6.1.4.1.19376.1.5.3.3 IHE PCC RoleCode 参见下文的IHE角色代码词表(IHERoleCode Vocabulary)
1.3.6.1.4.1.19376.1.5.3.4   用于CDA 2.0版IHE扩展的名称空间OID(Namespace OID used for IHE Extensions to CDA Release 2.0)
2.16.840.1.113883.10.20.1 CCD Root OID ASTM/HL7连续性照护文档(Continuity of Care Document,CCD)所使用的根节点OID
2.16.840.1.113883.5.112 RouteOfAdministration 参见HL7用药途径词表(RouteOfAdministration Vocabulary)
2.16.840.1.113883.5.1063 SeverityObservation 参见HL7严重程度词表(SeverityObservation Vocabulary)
2.16.840.1.113883.6.1 LOINC 观测指标标识符逻辑命名与编码系统(Logical Observation Identifier Names and Codes)
2.16.840.1.113883.6.96 SNOMED-CT 医学术语系统命名法-临床术语(SNOMED Clinical Terms
2.16.840.1.113883.6.103 ICD-9CM (诊断代码) 国际疾病分类临床·临床修订本·第9版(International Classification of Diseases, Clinical Modification, Version 9)
2.16.840.1.113883.6.104 ICD-9CM (操作项目代码) 国际疾病分类临床·临床修订本·第9版(International Classification of Diseases, Clinical Modification, Version 9)
2.16.840.1.113883.6.26 MEDCIN 一部来自MEDICOMP系统(MEDICOMP Systems)的分类系统。
2.16.840.1.113883.6.88 RxNorm RxNorm
2.16.840.1.113883.6.63 FDDC First DataBank药物代码(First DataBank Drug Codes)
2.16.840.1.113883.6.12 C4 当代操作项目术语集·第4版(Current Procedure Terminology 4,CPT-4)代码。
2.16.840.1.113883.6.257 长期照护最小数据集(Minimum Data Set for Long Term Care) 最小数据集答案列表(The root OID for Minimum Data Set Answer Lists)

IHE格式代码(IHE Format Codes)

下表列出的是PCC技术框架之中所规定的那些IHE概貌所采用的格式代码(format codes)、模板标识符(template identifiers)以及媒体类型(media types);同时,出于引用目的,其中还列出了同样那些用于来自其他委员会的其他精选IHE概貌的取值。
请注意,这些代码所属的编码系统(code system)为1.3.6.1.4.1.19376.1.2.3。这时ITI领域(ITI Domain)为那些用于跨机构文档共享(cross-enterprise document sharing,XDS)目的的代码所指定的编码系统。有关详情,请参见XDS编码系统 (1.3.6.1.4.1.19376.1.2.3)

概貌英文名称 概貌中文名称 格式代码
Format Code
媒体类型
Media Type
模板标识符
Template ID
2006年概貌(2006 Profiles)
Medical Summaries (XDS-MS) 医疗摘要 urn:ihe:pcc:xds-ms:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.3 (转诊介绍)
1.3.6.1.4.1.19376.1.5.3.1.1.4 (出院摘要)
2007年概貌(2007 Profiles)
Exchange of Personal Health Records (XPHR) 个人健康档案交换 urn:ihe:pcc:xphr:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.5 (摘录)
1.3.6.1.4.1.19376.1.5.3.1.1.6 (更新)
Emergency Department Referral (EDR) 急诊科转诊介绍 urn:ihe:pcc:edr:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.10
2008年概貌(2008 Profiles)
Antepartum Summary (APS) 产前摘要 urn:ihe:pcc:aps:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.11.2
Emergency Department Encounter Summary (EDES) 急诊科就医摘要 urn:ihe:pcc:edes:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 (分诊记录)

1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 (护理记录)
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 (分诊与护理综合记录)
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 (医师记录)

2009年概貌(2009 Profiles)
Antepartum History and Physical (APHP) 产前病史与体格检查 urn:ihe:pcc:aphp:2008 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
Antepartum Laboratory (APL) 产前实验室 urn:ihe:pcc:apl:2008 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2
Antepartum Education (APE) 产前教育 urn:ihe:pcc:ape:2008 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3
Immunization Content (IC) 免疫接种内容 urn:ihe:pcc:ic:2009 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 (免疫接种内容)
Care Management (CM) 照护管理 urn:ihe:pcc:cm:2008 text/xml  
ITI概貌(ITI Profiles)
Scanned Documents (PDF) 扫描文档(PDF) urn:ihe:iti:xds-sd:pdf:2008 text/xml 1.3.6.1.4.1.19376.1.2.20 (扫描文档)
Scanned Documents (text) 扫描文档(文本) rn:ihe:iti:xds-sd:text:2008 text/xml 1.3.6.1.4.1.19376.1.2.20 (扫描文档)
Basic Patient Privacy Consents (BPPC) 基本病人隐私知情同意书 urn:ihe:iti:bppc:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.7 (没有扫描文档部分的BPPC)
Basic Patient Privacy Consents with Scanned Document 备有扫描文档的基本病人隐私知情同意书 urn:ihe:iti:bppc-sd:2007 text/xml 1.3.6.1.4.1.19376.1.5.3.1.1.7.1 (备有扫描文档部分的BPPC)
实验室概貌(LAB Profiles)
CDA Laboratory Report CDA实验室报告 urn:ihe:lab:xd-lab:2008 text/xml 1.3.6.1.4.1.19376.1.3.3 (实验室报告)

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?


IHE角色代码词表(IHERoleCode Vocabulary)

IHE角色代码词表(IHERoleCode Vocabulary)是由HL7角色代码词表(HL7 Role Code vocabulary)目前并不支持的角色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1.3.5.1.4.1.19376.1.5.3.3。

IHE角色代码词表(IHERoleCode Vocabulary)
代码 代码中文名称 描述
EMPLOYER 雇主 某个人员的雇主。
SCHOOL 学校 一个人所就读的学校。
AFFILIATED 所属组织机构 一个人所隶属的组织机构(比如,某家志愿者组织)。
PHARMACY 药房 一个人所使用的药房。

参见