N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆICS35.240.80 团 体 标 准 T/CIATCM 068—2020 中医外科（疮疡血管外科）电子病历基本数 据集 Basic datasets of electronic medical record in specialty of surgery in Traditional Chinese Medicine 2020-10-15发布 2020-10-31实施 中国中医药信息学会 发 布 全国团体标准信息平台 N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆT/CIATCM 068—2020 I目 次 前 言 ................................................................................................................................................................. III 1 范围 ................................................................................................................................................................... 1 2 规范性引用文件 ............................................................................................................................................... 1 3术语和定义 ....................................................................................................................................................... 1 4 数据集元数据属性 ........................................................................................................................................... 2 5 数据元属性 ....................................................................................................................................................... 2 5.1 数据元公用属性 ................................................................................................................................... 2 5.2 数据元专用属性 ................................................................................................................................... 2 5.2.1 病历概要部分 ........................................................................................................................... 3 5.2.2 门（急）诊病历部分 ............................................................................................................... 3 5.2.3 门（急）诊处方部分 ............................................................................................................... 3 5.2.4 检查检验记录部分 ................................................................................................................... 3 5.2.5 一般治疗处置记录部分 ........................................................................................................... 6 5.2.6 助产记录部分 ........................................................................................................................... 8 5.2.7 护理操作记录部分 ................................................................................................................... 8 5.2.8 护理评估与计划部分 ............................................................................................................... 8 5.2.9 知情告知信息部分 ................................................................................................................... 9 5.2.10 住院病案首页部分 ................................................................................................................. 9 5.2.11 中医住院病案首页部分 ........................................................................................................ 9 5.2.12 入院记录部分 ......................................................................................................................... 9 5.2.13 住院病程记录部分 ................................................................................................................. 19 5.2.14 住院医嘱部分 ......................................................................................................................... 19 5.2.15 出院小结部分 ......................................................................................................................... 20 5.2.16 转诊（院）记录部分 ............................................................................................................. 20 5.2.17 医疗机构信息部分 ................................................................................................................. 20 6 数据元值域代码表 ...