Difference between revisions of "PCC Vocabulary Registry and Data Dictionary/zh"
Jump to navigation
Jump to search
| Line 9: | Line 9: | ||
{| class="wikitable" | {| class="wikitable" | ||
| − | ! | + | !章!! 英文描述 !! 中文描述 !! 状态 !! OID空间 |
|- | |- | ||
| − | | 3 || [[PCC_TF-1/XDS-MS|Cross-Enterprise Sharing of Medical Summaries (XDS-MS)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.2 | + | | 3 || [[PCC_TF-1/XDS-MS|Cross-Enterprise Sharing of Medical Summaries (XDS-MS)]] [[PCC_TF-1/XDS-MS|Cross-Enterprise Sharing of Medical Summaries (XDS-MS)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.2 |
|- | |- | ||
| − | | 4 || [[PCC_TF-1/XPHR|Exchange of Personal Health Record Content (XPHR)]] || Final Text | + | | 4 || [[PCC_TF-1/XPHR|Exchange of Personal Health Record Content (XPHR)]] || [[PCC_TF-1/XPHR|Exchange of Personal Health Record Content (XPHR)]] || Final Text |
|- | |- | ||
| − | | 5 || [[PCC_TF-1/EDR|ED Referral (EDR)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.10 | + | | 5 || [[PCC_TF-1/EDR|ED Referral (EDR)]] || [[PCC_TF-1/EDR|ED Referral (EDR)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.10 |
|- | |- | ||
| − | | 6 || [[PCC_TF-1/FSA|Reserved for Functional Status Assessments (FSA)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.12 | + | | 6 || [[PCC_TF-1/FSA|Reserved for Functional Status Assessments (FSA)]] || [[PCC_TF-1/FSA|Reserved for Functional Status Assessments (FSA)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.12 |
|- | |- | ||
| − | | 7 || [[PCC_TF-1/EDES|Reserved for Emergency Department Encounter Summary (EDES)]] || Under Revision ||1.3.6.1.4.1.19376.1.5.3.1.1.13 | + | | 7 || [[PCC_TF-1/EDES|Reserved for Emergency Department Encounter Summary (EDES)]] || [[PCC_TF-1/EDES|Reserved for Emergency Department Encounter Summary (EDES)]] || Under Revision ||1.3.6.1.4.1.19376.1.5.3.1.1.13 |
|- | |- | ||
| − | | 8 || [[PCC_TF-1/QED|Reserved for Query for Existing Data (QED)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.14 | + | | 8 || [[PCC_TF-1/QED|Reserved for Query for Existing Data (QED)]] || [[PCC_TF-1/QED|Reserved for Query for Existing Data (QED)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.14 |
|- | |- | ||
| − | | 9 || [[PCC_TF-1/APR|Antepartum Record (APR)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.16 | + | | 9 || [[PCC_TF-1/APR|Antepartum Record (APR)]] || [[PCC_TF-1/APR|Antepartum Record (APR)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.16 |
|- | |- | ||
| − | | 10 || [[PCC_TF-1/CM|Care Management (CM)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.17 | + | | 10 || [[PCC_TF-1/CM|Care Management (CM)]] || [[PCC_TF-1/CM|Care Management (CM)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.17 |
|- | |- | ||
| − | | 11 || [[PCC_TF-1/IC|Immunization Content (IC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.18 | + | | 11 || [[PCC_TF-1/IC|Immunization Content (IC)]] || [[PCC_TF-1/IC|Immunization Content (IC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.18 |
|- | |- | ||
| − | | 12 || [[PCC_TF-1/CND|Patient Plan of Care (PPOC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.20 | + | | 12 || [[PCC_TF-1/CND|Patient Plan of Care (PPOC)]] || [[PCC_TF-1/CND|Patient Plan of Care (PPOC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.20 |
|- | |- | ||
| − | | 13 || [[PCC_TF-1/QCG|Request for Clincal Guidance (QCG)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.?? | + | | 13 || [[PCC_TF-1/QCG|Request for Clincal Guidance (QCG)]] || [[PCC_TF-1/QCG|Request for Clincal Guidance (QCG)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.?? |
|- | |- | ||
| − | | 13 || [[PCC_TF-1/PPCR|EMS Transfer of Care (ETC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.19 | + | | 13 || [[PCC_TF-1/PPCR|EMS Transfer of Care (ETC)]] || [[PCC_TF-1/PPCR|EMS Transfer of Care (ETC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.19 |
|- | |- | ||
| − | | 13 || [[PCC_TF-1/LDR|Labor and Delivery Record (LDR)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.21 | + | | 13 || [[PCC_TF-1/LDR|Labor and Delivery Record (LDR)]] || [[PCC_TF-1/LDR|Labor and Delivery Record (LDR)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.21 |
|- | |- | ||
| − | | A || Actor Descriptions | + | | A || Actor Descriptions|| Actor Descriptions |
|- | |- | ||
| − | | B || Transaction Descriptions | + | | B || Transaction Descriptions|| Transaction Descriptions |
|- | |- | ||
| − | | C || How to Prepare and IHE Integration Statement | + | | C || How to Prepare and IHE Integration Statement|| How to Prepare and IHE Integration Statement |
|} | |} | ||
Revision as of 09:02, 3 March 2010
PCC词表注册库与数据字典（PCC Vocabulary Registry and Data Dictionary）
本页面列出的是PCC委员会所掌控的各种词表和数据字典。在没有与PCC委员会进行协调的情况下，请勿编辑此页面。本页面旨在作为现行指定术语等的可靠参考。在PCC概貌文档记录尚未完善之前，不应当对某些术语赋予永久取值。
第1卷：小节与附录
第2卷：交易与小节编号
| Number | Section and Transaction Name |
|---|---|
| PCC-1 | Query Existing Data |
| PCC-7 | Guideline Notification |
| PCC-8 | Request Guideline Data |
| PCC-9 | Care Management Data Query |
| PCC-10 | V3 Care Management Update |
| PCC-11 | V2 Care Management Update |
| Chapter | Description |
|---|---|
| 5.3.1 | Folder Content Module Reserved for APS |
| 5.4.1.10 - 13 | Document Content Modules Reserved for APS |
PCC模板标识符
| 模板标识符 | 英文描述 | 中文描述 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1 | CDA Document Template Identifiers | CDA文档模板标识符 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.1 | Medical Document | 医疗文档 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.2 | Medical Summary Template Identifier and XDS-MS formatCode | 医疗摘要模板标识符与XDS-MS格式代码 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.3 | Referral Summary | 转诊摘要 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.4 | Discharge Summary | 出院摘要 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 | History and Physical | 病史与体格检查 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.5 | PHR Extract | 个人健康档案摘录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.6 | PHR Update | 个人健康档案更新 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.7 | Basic Patient Privacy Consent (BPPC) | 基本病人隐私知情同意书 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10 | Emergency Department Referral (EDR) | 急诊科转诊介绍 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | Antepartum Summary | 产前摘要 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 | Triage Note | 治疗类选记录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 | Nursing Note | 护理记录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 | Composite Triage and Nursing Note | 综合治疗类选与护理记录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 | ED Physician Note | 急诊科医师记录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 | Antepartum History and Physical | 产前病史与体格检查 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2 | Antepartum Laboratory | 产前实验室检验结果 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3 | Antepartum Education | 产前教育 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 | Immunization Detail | 免疫接种详情 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.19.1 | Prehospital Patient Care Report | 院前病人照护报告 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 | Care Plan | 照护计划 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.2 | Subsequent Evaluation Note | 后续评价记录 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 | Labor and Delivery Admission History and Physical | 分娩入院病史与体格检查 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.2 | Labor and Delivery Summary | 分娩摘要 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.3 | Maternal Discharge Summary | 产妇出院摘要 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2 | CDA Header Template Identifiers | CDA标头模板标识符 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.1 | Language Communication | 语言交流 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.2 | Employer and School Contacts | 雇主与学校联系方式 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.3 | Healthcare Providers and Pharmacies | 医疗保健服务提供者与药房 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4 | Patient Contacts | 病人联系方式 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4.1 | Spouse | 配偶 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4.2 | Natural Father of Fetus | 胎儿生父 | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.5 | Authorization | 授权 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3 | CDA Section Template Identifiers | CDA小节模板标识符 | |
| Reasons For Care | 照护原因 | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.1 | Reason for Referral | 转诊原因 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.2 | Reason for Referral (coded) | 转诊原因 （编码型） | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 | Chief Complaint | 主诉 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.3 | Hospital Admission Diagnosis | 医院入院诊断 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.1 | Proposed Procedure | 建议操作项目 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.2 | Estimated Blood Loss | 预计失血量 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.3 | Proposed Anesthesia | 建议麻醉方法 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.4 | Reason for Procedure | 操作项目原因/理由 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1 | Reason for Visit | 就诊原因/理由 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | Mode of Arrival | 到达方式 | |
| Other Condition Histories | 其他健康状况史 | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.4 | History of Present Illness | 现病史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.5 | Hospital Course | 在院过程/住院过程 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.6 | Active Problems | 现存问题 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.7 | Discharge Diagnosis | 出院诊断 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.8 | History of Past Illness | 既往病史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 | Encounter Histories | 就医史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.9 | History of Outpatient Visits | 门诊就诊史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.10 | History of Inpatient Visits | 住院就诊史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.11 | List of Surgeries | 手术列表 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.12 | Coded List of Surgeries | 编码型手术列表 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.13 | Allergies and Other Adverse Reactions | 变态反应及其他不良反应 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.14 | Family Medical History | 家族医学史/家族史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.15 | Coded Family Medical History | 编码型家族医学史/家族史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.5 | Pre-procedure Family Medical History | 操作前家族医学史/家族史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.16 | Social History | 社会史 | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.17 | Functional Status | 功能状态 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 | Coded Functional Status | 编码型功能状态 | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2 | Pain Scale Assessment | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3 | Braden Score Assessment | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4 | Geriatric Depression Scale | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 | Physical Function | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.18 | Review of Systems | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.13 | Preprocedure Review of Systems | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 | Hazardous Working Conditions | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 | Pregnancy History | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 | Estimated Delivery Dates Section | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 | Medical Devices | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6 | Foreign Travel | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.8 | History of Tobacco Use | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.10 | Current Alcohol/Substance Abuse | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.12 | Transfusion History | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.14 | Anesthesia Risk Review of Systems | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.46 | Implanted Medical Device Review | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.47 | Pregnancy Status Review | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1 | History of Infection | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1.1 | Coded History of Infection | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 | Coded Social History | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2 | Prenatal Events | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 | Labor and Delivery | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 | Newborn Delivery Information | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.7 | Post-partum Treatment | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.8 | Newborn Status at Maternal Discharge | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.9 | Event Outcomes | ||
| Medications | |||
| 1.3.6.1.4.1.19376.1.5.3.1.3.19 | Medications | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.20 | Admission Medication History | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.21 | Medications Administered | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.22 | Hospital Discharge Medications | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.23 | Immunizations | ||
| Physical Exams | |||
| 1.3.6.1.4.1.19376.1.5.3.1.3.24 | Physical Exam | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 | Physical Exam (with subsections) | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.26 | Hospital Discharge Physical Exam | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.25 | Vital Signs | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 | Coded Vital Signs | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 | General Appearance | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.48 | Visible Implanted Medical Devices | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 | Integumentary System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 | Head | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 | Eyes | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 | Ears, Nose, Mouth and Throat | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 | Ears | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 | Nose | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 | Mouth, Throat, and Teeth | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 | Neck | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 | Endocrine System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 | Thorax and Lungs | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 | Chest Wall | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 | Breasts | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 | Heart | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 | Respiratory System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 | Abdomen | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 | Lymphatic System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 | Vessels | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.34 | Musculoskeletal System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 | Neurologic System | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 | Genitalia | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 | Rectum | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 | Extremeties | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 | Coded Physical Exam | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10 | Pelvis | ||
| Relevant Studies | |||
| 1.3.6.1.4.1.19376.1.5.3.1.3.27 | Results | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.28 | Coded Results | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.29 | Hospital Studies Summary | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.30 | Coded Hospital Studies Summary | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 | Consultations | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5 | Antenatal Testing and Surveillance | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1 | Coded Antenatal Testing and Surveillance | ||
| Plans of Care | |||
| 1.3.6.1.4.1.19376.1.5.3.1.3.31 | Care Plan | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 | Assessment and Plan | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.33 | Discharge Diet | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.34 | Advance Directives | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.35 | Coded Advance Directives | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 | Procedure Care Plan | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.45 | Procedure Care Plan Status Report | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 | Health Maintenance Care Plan | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.41 | Health Maintenance Care Plan Status Report | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | Transport Mode | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.2.1 | Birth Plan | ||
| Procedures Performed | |||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 | Patient Education and Consents | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.39 | Coded Patient Education and Consents | ||
|
Procedures Performed |
|||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 | Intravenous Fluids Administered | ||
| Impressions | |||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.42 | Pre-procedure Impressions | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.44 | Pre-procedure Risk Assessment | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 | Visit Summary Flowsheet Section | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7 | Progress Note | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 | ED Diagnoses | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2 | Acuity Assessment | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 | Assessments | ||
| Administrative and Other Information | |||
| 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 | Payers | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 | Referral Source | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | Mode of Arrival | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 | ED Disposition | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4 | CDA Entry Template Identifiers | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.1 | Severity | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 | Problem Status Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 | The template identifier used to identify a health status observation. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.2 | The template identifier used to identify a comment on an observation. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.3 | The template identifier used to identify instructions in medication order. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.3.1 | Medication Fulfillment Instructions | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.4 | The template identifier used to identify references to external documents. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 | Internal References | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.5.1 | The template identifier used to identify observation elements that indicate a concern. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 | The template identifier used to identify observation elements that indicate a problem of concern. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 | The template identifier used to identify observation elements that indicate an allergy or adverse reaction of concern. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.5 | The template identifier used to identify observation elements that describe patient problem. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.6 | The template identifier used to identify observation elements that describe patient allergy or adverse reaction. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.7 | The template identifier for a <substanceAdministration> event that records medication administration events or requests. This is the root template for all medications. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.12 | Immunizations | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.7.3 | Supply Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.7.2 | Product Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13 | Simple Observations | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 | Vital Signs Organizer | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.2 | Vital Signs Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.15 | Family History Organizer | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.3 | Family History Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 | Social History Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 | Pregnancy Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | Estimated Delivery Date Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 | Antepartum Visit Summary Battery | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.7 | Advance Directive Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.6 | Blood Type Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.14 | Encounters | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.16 | Update Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.19 | Procedure Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 | Transport | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 | Intended Encounter Disposition | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.17 | Coverage Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.18 | Payer Entry | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 | Pain Score Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2 | Braden Score Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3 | Braden Score Component | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4 | Geriatric Depression Score Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5 | Geriatric Depression Score Component | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7 | Survey Panel | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6 | Survey Observation | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1 | Acuity | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2 | Intravenous Fluids Administered | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4 | Nursing Assessments Battery | ||
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.3.10 | Antenatal Testing and Surveillance Battery | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.7.1 | This template identifier identifies medications that do not require complex processing for dose (e.g., split, tapered, conditional dosing or combination medications). | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.8 | The template identifier for a <substanceAdministration> event that records tapered dose information in subordinate <substanceAdministration> events. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.9 | The template identifier for a <substanceAdministration> event that records split dose information in subordinate <substanceAdministration> events. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.10 | The template identifier for a <substanceAdministration> event that records conditional dose information in subordinate <substanceAdministration> events. | ||
| 1.3.6.1.4.1.19376.1.5.3.1.4.11 | The template identifier for a <substanceAdministration> event that records combination medication component information in subordinate <substanceAdministration> events. | ||
第2卷：附录
| Chapter | Description |
|---|---|
| A | Examples |
| B | Validating CDA Documents |
| C | Extensions to CDA Release 2.0 |
参见
- PCC技术框架乃是正式的主文档。
- PCC名称空间与词表