PCC Vocabulary Registry and Data Dictionary/zh

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PCC词表注册库与数据字典(PCC Vocabulary Registry and Data Dictionary)



英文描述 中文描述 状态 OID空间
3 Cross-Enterprise Sharing of Medical Summaries (XDS-MS) 医疗服务摘要跨机构共享(Cross-Enterprise Sharing of Medical Summaries,XDS-MS) 最终文本
4 Exchange of Personal Health Record Content (XPHR) 个人健康档案内容交换(Exchange of Personal Health Record Content,XPHR) 最终文本
5 ED Referral (EDR) 急诊转诊介绍(ED Referral,EDR) 最终文本
6 Reserved for Functional Status Assessments (FSA) 预留用于功能状态评估(Functional Status Assessments,FSA) 正在修订
7 Reserved for Emergency Department Encounter Summary (EDES) 预留用于急诊科就医摘要(Emergency Department Encounter Summary,EDES) 正在修订
8 Reserved for Query for Existing Data (QED) 预留用于查询现有数据(Query for Existing Data,QED) 试行
9 Antepartum Record (APR) 产前档案(Antepartum Record,APR) 正在修订
10 Care Management (CM) 照护管理(Care Management,CM) 试行
11 Immunization Content (IC) 免疫接种内容(Immunization Content,IC) 试行
12 Patient Plan of Care (PPOC) 病人照护计划(Patient Plan of Care,PPOC) 试行
13 Request for Clincal Guidance (QCG) 临床指导请求(Request for Clincal Guidance,QCG) 试行
13 EMS Transfer of Care (ETC) 急救医疗服务转交(EMS Transfer of Care,ETC) 试行
13 Labor and Delivery Record (LDR) 分娩档案(Labor and Delivery Record,LDR) 正在修订
A Actor Descriptions 角色描述
B Transaction Descriptions 交易描述
C How to Prepare and IHE Integration Statement 如何编制IHE集成声明(IHE Integration Statement)


编号 小节及交易英文名称 小节及交易中文名称
PCC-1 Query Existing Data 查询现有数据
PCC-7 Guideline Notification 诊疗指南通知
PCC-8 Request Guideline Data 请求诊疗指南数据
PCC-9 Care Management Data Query 照护管理数据查询
PCC-10 V3 Care Management Update V3 照护管理更新
PCC-11 V2 Care Management Update V2 照护管理更新
英文描述 中文描述
5.3.1 Folder Content Module Reserved for APS 为APS预留的文件夹内容模块 - 13 Document Content Modules Reserved for APS 为APS预留的文档内容模块



模板标识符 英文描述 中文描述 CDA Document Template Identifiers CDA文档模板标识符 Medical Document 医疗文档 Medical Summary Template Identifier and XDS-MS formatCode 医疗摘要模板标识符与XDS-MS格式代码 Referral Summary 转诊摘要 Discharge Summary 出院摘要 History and Physical 病史与体格检查 PHR Extract 个人健康档案摘录 PHR Update 个人健康档案更新 Basic Patient Privacy Consent (BPPC) 基本病人隐私知情同意书 Emergency Department Referral (EDR) 急诊科转诊介绍 Antepartum Summary 产前摘要 Triage Note 分诊记录 Nursing Note 护理记录 Composite Triage and Nursing Note 分诊与护理综合记录 ED Physician Note 急诊科医师记录 Antepartum History and Physical 产前病史与体格检查 Antepartum Laboratory 产前实验室检验结果 Antepartum Education 产前教育 Immunization Detail 免疫接种详情 Prehospital Patient Care Report 院前病人照护报告 Care Plan 照护计划 Subsequent Evaluation Note 后续评价记录 Labor and Delivery Admission History and Physical 分娩入院病史与体格检查 Labor and Delivery Summary 分娩摘要 Maternal Discharge Summary 产妇出院摘要 CDA Header Template Identifiers CDA标头模板标识符 Language Communication 语言交流 Employer and School Contacts 雇主与学校联系方式 Healthcare Providers and Pharmacies 医疗保健服务提供者与药房 Patient Contacts 病人联系方式 Spouse 配偶 Natural Father of Fetus 胎儿生父 Authorization 授权 CDA Section Template Identifiers CDA小节模板标识符
Reasons For Care 照护原因 Reason for Referral 转诊原因 Reason for Referral (coded) 转诊原因 (编码型) Chief Complaint 主诉 Hospital Admission Diagnosis 医院入院诊断 Proposed Procedure 建议操作项目 Estimated Blood Loss 预计失血量 Proposed Anesthesia 建议麻醉方法 Reason for Procedure 操作项目原因/理由 Reason for Visit 就诊原因/理由 Mode of Arrival 到达方式
Other Condition Histories 其他健康状况史 History of Present Illness 现病史 Hospital Course 在院过程/住院过程 Active Problems 现存问题 Discharge Diagnosis 出院诊断 History of Past Illness 既往病史 Encounter Histories 就医史 History of Outpatient Visits 门诊就诊史 History of Inpatient Visits 住院就诊史 List of Surgeries 手术列表 Coded List of Surgeries 编码型手术列表 Allergies and Other Adverse Reactions 变态反应及其他不良反应 Family Medical History 家族医学史/家族史 Coded Family Medical History 编码型家族医学史/家族史 Pre-procedure Family Medical History 操作前家族医学史/家族史 Social History 社会史 Functional Status 功能状态 Coded Functional Status 编码型功能状态 Pain Scale Assessment 疼痛量表评估 Braden Score Assessment Braden分值评估 Geriatric Depression Scale 老年抑郁症量表 Physical Function 躯体功能 Review of Systems 多系统回顾 Preprocedure Review of Systems 操作前多系统回顾 Hazardous Working Conditions 有害工作条件 Pregnancy History 妊娠史 Estimated Delivery Dates Section 预产期小节 Medical Devices 医疗装置/医疗设备 Foreign Travel 出国旅行 History of Tobacco Use 吸烟史/烟草使用史 Current Alcohol/Substance Abuse 当前酒精/物质滥用情况 Transfusion History 输血史 Anesthesia Risk Review of Systems 麻醉风险多系统回顾 Implanted Medical Device Review 植入型医疗装置回顾 Pregnancy Status Review 妊娠状态回顾 History of Infection 感染史 Coded History of Infection 编码型感染史 Coded Social History 编码型社会史 Prenatal Events 产前事件 Labor and Delivery 分娩 Newborn Delivery Information 新生儿生产信息 Post-partum Treatment 产后处理 Newborn Status at Maternal Discharge 产妇出院时的新生儿状态 Event Outcomes 事件结局
Medications 用药情况 Medications 用药情况 Admission Medication History 住院用药史 Medications Administered 已施用的药物 Hospital Discharge Medications 医院出院药物 Immunizations 免疫接种
Physical Exams 体格检查 Physical Exam 体格检查 Physical Exam (with subsections) 体格检查(带有子小节) Hospital Discharge Physical Exam 医院出院体格检查 Vital Signs 生命体征 Coded Vital Signs 编码型生命体征 General Appearance 全身状况 Visible Implanted Medical Devices 可见的植入型医疗装置 Integumentary System 皮肤系统 Head 头部 Eyes 眼睛 Ears, Nose, Mouth and Throat 口部与耳鼻喉 Ears 耳部 Nose Mouth, Throat, and Teeth 口腔、咽喉及牙齿 Neck 颈部 Endocrine System 内分泌系统 Thorax and Lungs 胸腔与肺部 Chest Wall 胸壁 Breasts 乳房 Heart 心脏 Respiratory System 呼吸系统 Abdomen 腹部 Lymphatic System 淋巴系统 Vessels 脉管 Musculoskeletal System 肌肉骨骼系统 Neurologic System 神经系统 Genitalia 生殖器 Rectum 直肠 Extremeties 四肢 Coded Physical Exam 编码型体格检查 Pelvis 盆腔
Relevant Studies 相关检查 Results 结果 Coded Results 编码型结果 Hospital Studies Summary 医院检查摘要 Coded Hospital Studies Summary 编码型医院检查摘要 Consultations 会诊咨询 Antenatal Testing and Surveillance 产前检测与监测 Coded Antenatal Testing and Surveillance 编码型产前检测与监测
Plans of Care 照护计划 Care Plan 照护计划 Assessment and Plan 评估与计划 Discharge Diet 出院饮食 Advance Directives 事前指示 Coded Advance Directives 编码型事前指示 Procedure Care Plan 操作项目照护计划 Procedure Care Plan Status Report 操作项目照护计划状态报告 Health Maintenance Care Plan 健康维护照护计划 Health Maintenance Care Plan Status Report 健康维护照护计划状态报告 Transport Mode 运送方式 Birth Plan 出生计划
Procedures Performed 已执行的操作项目 Patient Education and Consents 病人教育及知情同意书 Coded Patient Education and Consents 编码型病人教育及知情同意书 Procedures Performed 已执行的操作项目 Intravenous Fluids Administered 已施用的静脉内液体
Impressions 印象 Pre-procedure Impressions 操作前印象 Pre-procedure Risk Assessment 操作前风险评估 Visit Summary Flowsheet Section 就诊摘要流程图小节 Progress Note 病程记录 ED Diagnoses 急诊科诊断/急诊诊断 Acuity Assessment 紧急程度评估 Assessments 评估
Administrative and Other Information 管理信息及其他信息 Payers 支付方 Referral Source 转诊来源 Mode of Arrival 到达方式 ED Disposition 急诊科处置/急诊处置 CDA Entry Template Identifiers CDA条目模板标识符 Severity 严重程度 Problem Status Observation 问题状态观察结果 The template identifier used to identify a health status observation. 用于标识健康状态观察结果的模板标识符 The template identifier used to identify a comment on an observation. 用于标识特定观察结果注释的模板标识符 The template identifier used to identify instructions in medication order. 用于标识用药医嘱说明的模板标识符 Medication Fulfillment Instructions 用药说明 The template identifier used to identify references to external documents. 用于标识外部文档引用信息的模板标识符 Internal References 内部引用信息 The template identifier used to identify observation elements that indicate a concern. 用于标识表示所关注特定事项的观察结果要素的模板标识符 The template identifier used to identify observation elements that indicate a problem of concern. 用于标识表示所关注特定问题的观察结果要素的模板标识符 The template identifier used to identify observation elements that indicate an allergy or adverse reaction of concern. 用于标识表示所关注特定变态反应或不良反应的观察结果要素的模板标识符 The template identifier used to identify observation elements that describe patient problem. 用于标识描述病人问题的观察结果要素的模板标识符 The template identifier used to identify observation elements that describe patient allergy or adverse reaction. 用于标识描述病人变态反应或不良反应的观察结果要素的模板标识符 The template identifier for a <substanceAdministration> event that records medication administration events or requests. This is the root template for all medications. 用于记录用药事件或申请的<substanceAdministration>(物质施用)事件的模板标识符。这是所有用药活动的根模板。 Immunizations 免疫接种 Supply Entry 供应条目 Product Entry 产品条目 Simple Observations 简单观察结果 Vital Signs Organizer 生命体征编组器 Vital Signs Observation 生命体征观察结果 Family History Organizer 家族史编组器 Family History Observation 家族史观察结果 Social History Observation 社会史观察结果 Pregnancy Observation 妊娠观察结果 Estimated Delivery Date Observation 预产期观察结果 Antepartum Visit Summary Battery 产前就诊摘要组套 Advance Directive Observation 事前指示观察结果 Blood Type Observation 血型观察结果 Encounters 就医过程 Update Entry 更新条目 Procedure Entry 操作项目条目 Transport 运送 Intended Encounter Disposition 预定就医处置 Coverage Entry 保险范围条目 Payer Entry 支付方条目 Pain Score Observation 疼痛评分观察结果 Braden Score Observation Braden分值观察结果 Braden Score Component Braden分值构成要素 Geriatric Depression Score Observation 老年抑郁症分值观察结果 Geriatric Depression Score Component 老年抑郁症分值构成要素 Survey Panel 问卷调查组合 Survey Observation 问卷调查观察结果 Acuity 紧急程度 Intravenous Fluids Administered 已施用的静脉内液体 Nursing Assessments Battery 护理学评估组套 Antenatal Testing and Surveillance Battery 产前检测与监测组合 This template identifier identifies medications that do not require complex processing for dose (e.g., split, tapered, conditional dosing or combination medications). 用于标识那些无需复杂剂量处理的药物的模板标识符 The template identifier for a <substanceAdministration> event that records tapered dose information in subordinate <substanceAdministration> events. <substanceAdministration>(物质施用)事件模板标识符,用于在下属<substanceAdministration>事件之中记录剂量递减信息。 The template identifier for a <substanceAdministration> event that records split dose information in subordinate <substanceAdministration> events. <substanceAdministration>(物质施用)事件模板标识符,用于在下属<substanceAdministration>事件之中记录剂量拆分信息。 The template identifier for a <substanceAdministration> event that records conditional dose information in subordinate <substanceAdministration> events. <substanceAdministration>(物质施用)事件模板标识符,用于在下属<substanceAdministration>事件之中记录条件剂量信息。 The template identifier for a <substanceAdministration> event that records combination medication component information in subordinate <substanceAdministration> events. <substanceAdministration>(物质施用)事件模板标识符,用于在下属<substanceAdministration>事件之中记录联合用药构成要素信息。


英文描述 中文描述
A Examples 示例
B Validating CDA Documents 验证 CDA 文档
C Extensions to CDA Release 2.0 对 CDA 2.0版 的扩展