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 064 —2020 中医皮肤科电子病历基本数据集 Basic datasets for electronic medical records in dermatology specialty 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 064 —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 ......................................................................................................................... 8 5.2.4 检查检验记录部分 ........................................................................................................................... 10 5.2.5 一般治疗处置记录部分 ................................................................................................................... 18 5.2.6 护理操作记录部分 ........................................................................................................................... 18 5.2.7 护理评估与计划部分 ....................................................................................................................... 18 5.2.8 知情告知信息部分 ........................................................................................................................... 18 5.2.9 住院病案首页部分 ........................................................................................................................... 19 5.2.10 中医住院病案首页部分 ................................................................................................................. 19 5.2.11 入院记录部分 ................................................................................................................................. 19 5.2.12 住院病程记录部分 ......................................................................................................................... 23 5.2.13 住院医嘱部分 ................................................................................................................................. 24 5.2.14 出院小结部分 ................................................................................................................................. 24 5.2.15 转诊（院）记录部分 ..................................................................................................................... 24 5.2.16 医疗机构信息部分 ......................................................................................................................... 24 6 数据元值域代码表