TCIATCM0702020名老中医典型病案共享数据库建设指南

ICS GuidelinesonconstructionoftheshareddatabaseoftypicalcasestreatedbyprestigousphysiciansofTradtionalChineseMedicine 中国中医药信息学 发T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070— 前 IT技术规 附录A（资料性附录）名老中医典型病案共享数据库建设指 附录B（资料性附录）名老中医典型病案共享数据库建设指 T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—GB/T2260-2013中华人民共和国行政区划代码GB/T2261.1-2003个人基本信息分类与代码第1部分：人的性别代码GB/T2261.2-2003个人基本信息分类与代码第2部分：婚姻状况代码GB/T3304-1991中国各民族名称的罗马字母拼写法和代码GB/T4761-2008GB/T7408-2005数据元和交换格式信息交换GB/T10114-2003县级以下行政区划代码编制规则GB/T15657-1995GB/T16751.3GB/T22239-2019信息安全技术WS/T303-2009卫生信息数据元标准化规则WS364-2011WS371-2012WS445.11-2014WS/T447-2014T/CIATCM058-2019中医药信息标准编制通则ICD-1010GB/T7408、GB/T18391.3、WS/T303、WS/T305、WS/T306、WS363、TCIATCM037-2019extensiblemarkupclinicaldocumentCPOE：计算机化医生医嘱录入系统(ComputerizedPhysicianOrderEntry)EMR：电子病历（ElectronicMedicalRecord）HIS：医院信息系统（HospitalInformationSystem）HL7：卫生信息交换标准（HealthLevel7）HMIS：医院管理信息系统(HospitalManagementInformationSystem)LIS：实验室信息系统（LaboratoryInformationSystem）PACS：图像归档和通信系统（PictureArchivingandCommunicationSystem）RIS：放射科信息系统(RadiographyInformationSystem)TCD：中医病证分类与代码（ClassificationandcodesofdiseasesandZHENGOfTraditionalChinese（HL）（OD）ETL等数在数据库建设中，尽可能采用国际、国内医学领域相关标准，如TCD、ICD10等，以符合流程的标问、切闻、问、切闻、问、切1EMR2。7.2.2据转换的过程中需要将业务系统的数据转换成名老中医典型病案共享知识库能够接收的数据具体内容见附录B表B.2-B.4。具体内容见附录BB.5-B.14具体内容见附录B表B.15-B.18。（HILISEMHIM等）EM领域及相关数据源参见附录B表B.13360ITITITIT管理员应遵循技术和管理相结合的原则进行设计和实施，保证各种安全技术与运行管理机制、A.1主诉（症状/体征症状：过敏（不良反应体格检查：功能（残疾疾病（外伤）PatientPatientMedicalB.2WS218-WS364.3-2011CV02.01.101GB/T2261.1-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—GB/T2261.2-WS364.15-2011CV08.30.005出生地（省GB/T2260-出生地（区、县GB/T2260-GB/T2659-GB/T3304-B.3WS218-GB/T2261.1-WS364.3-2011CV02.01.101B.4WS218-GB/T2261.1-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—WS364.3-2011CV02.01.101入院诊断（主诊断ICD-10入院诊断（中医病名）GB/T15657-入院诊断（中医证候）GB/T15657-WS364.12-2011CV06.00.101出院诊断（主诊断ICD-10出院诊断（中医病名）GB/T15657-出院诊断（中医证候）GB/T15657-B.5WS218-GB/T2261.1-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—GB/T15657-GB/T15657-WS218-GB/T2261.1-B.7WS218-WS364.16-2011CV08.50.002T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—B.8WS364.12-2011CV06.00.102总量（临时医嘱会使用WS218-WS445.4-CV06.00.227T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—B.9WS218-WS363.9-B.10WS218-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—B.11WS218-B.12WS218-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—B.14B.13WS218-WS218-给出强度（单次剂量给出强度单位（单次剂量单位WS364.16-2011CV08.50.002给出药品数量（最小单位WS364.12-2011CV06.00.102贴数（用于草药T/CIATCMT/CIATCM070—B.15T/CIATCMT/CIATCM070—WS218-时限要求（文字B.16WS218-TEXTWS218-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—WS218-WS218-GB/T2261.1-WS364.3-2011CV02.01.101WS218-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—WS218-WS218-GB/T2261.1-WS364.3-2011CV02.01.101T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—WS218-WS218-GB/T2261.1-WS364.15-2011CV08.30.005GB/T2261.4-GB/T3304-GB/T2659-T/CIATCMT/CIATCM070—T/CIATCMT/CIATCM070—WS364.3-2011CV02.01.101GB/T2261.2-GB/T4761-门（急）诊诊断（中医诊断）GB/T15657-门（急）诊诊断（中医症候）GB/T15657-门（急）诊诊断（西医诊断）GB/T16751.3-GB/T15657-GB/T15657-颅脑损伤患者昏迷时间_颅脑损伤患者昏迷时间_WS364