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 066 —2020 中医急诊科电子病历基本数据集 Basic datasets for electronic medical records in specialty of emergency in Traditional Chinese Medicine 中国中医药信息学会 发 布2020-10-15发布 2020-10-31实施 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 066 —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 ......................................................................................................................................... 1 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 ................................................................................................................................... 2 5.2.2 门（急）诊病历部分 ....................................................................................................................... 3 5.2.3 门（急）诊处方部分 ..................................................................................................................... 10 5.2.4 检查检验记录部分 ......................................................................................................................... 12 5.2.5 一般治疗处置记录部分 ................................................................................................................. 16 5.2.6 助产记录部分 ................................................................................................................................. 16 5.2.7 护理操作记录部分 ......................................................................................................................... 16 5.2.8 护理评估与计划部分 ..................................................................................................................... 16 5.2.9 知情告知信息部分 ......................................................................................................................... 17 5.2.10 住院病案首页部分 ....................................................................................................................... 17 5.2.11 中医住院病案首页部分 ............................................................................................................... 17 5.2.12 入院记录部分 ............................................................................................................................... 18 5.2.13 住院病程记录部分 ....................................................................................................................... 27 5.2.14 住院医嘱部分 ............................................................................................................................... 30 5.2.15 出院小结部分 ............................................................................................................................... 30 5.2.16 转诊（院）记录部分 ................................................................................................................... 30 5.2.17 医疗机构信息部分 .........................