醫(yī)院信息平臺交互標準 第8部分：醫(yī)囑信息交互服務

1、Q/LB.XXXXX-XXXXICS 11.020CCS C 07WS中華人民共和國衛(wèi)生行業(yè)標準XX/T XXXXXXXXX醫(yī)院信息平臺交互標準第8部分：醫(yī)囑信息交互服務Hospital information platform interactive standardPart 2：Order information interactive servicesXXXX - XX - XX發(fā)布XXXX - XX - XX實施中華人民共和國國家衛(wèi)生健康委員會發(fā)布XX/T XXXXXXXXX目次前言II1 范圍32 規(guī)范性引用文件33 術語和定義34 交互服務3附錄A（規(guī)范性） 消息示例2446前言本

2、標準是WS/T XXXXX醫(yī)院信息平臺交互標準的第8部分。WS/T XXXXX已經發(fā)布以下部分：第1部分：總則第2部分：個人信息注冊、查詢服務；第3部分：醫(yī)療衛(wèi)生機構注冊、查詢服務；第4部分：醫(yī)療衛(wèi)生人員注冊、查詢服務； 第5部分：術語注冊、查詢服務；第6部分：文檔注冊、查詢服務；第7部分：就診信息交互服務；第8部分：醫(yī)囑信息交互服務；第9部分：申請單信息交互服務；第10部分：預約信息交互服務；第11部分：狀態(tài)信息交互服務。本標準由國家衛(wèi)生健康標準委員會衛(wèi)生健康信息標準專業(yè)委員會負責技術審查和技術咨詢，由國家衛(wèi)生健康委統(tǒng)計信息中心負責協(xié)調性和格式審查，由國家衛(wèi)生健康委規(guī)劃發(fā)展與信息化司負責業(yè)務

3、管理、法規(guī)司負責統(tǒng)籌管理。本標準主要起草單位： 本標準主要起草人： 醫(yī)院信息平臺交互標準 第8部分：醫(yī)囑信息交互服務1 范圍本標準規(guī)定了醫(yī)囑信息交互服務消息的模板、消息架構的要求以及對消息內容的約束。本標準適用于醫(yī)囑信息交互服務的應用。2 規(guī)范性引用文件下列文件中的內容通過文中的規(guī)范性引用而構成本標準必不可少的條款。其中，注日期的引用文件，僅該日期對應的版本適用于本標準；不注日期的引用文件，其最新版本（包括所有的修改單）適用于本標準。WS/T XXX.1 醫(yī)院信息平臺交互標準 第1部分：總則3 術語和定義WS/T XXX.1中界定的術語和定義均適用于本標準。4 交互服務4.1 醫(yī)囑信息新增服務

4、（OrderInfoAdd）4.1.1 角色和交易4.1.1.1 角色交易圖醫(yī)囑信息新增服務的角色交易圖如圖1所示。圖1 醫(yī)囑信息新增服務角色交易圖4.1.1.2 角色的選擇醫(yī)囑信息新增服務的角色列表如表1所示。表1 醫(yī)囑信息新增服務角色列表角色交易選擇醫(yī)囑信息源醫(yī)囑信息新增必選項（R）醫(yī)囑信息新增服務醫(yī)囑信息新增必選項（R）4.1.1.3 交易流程醫(yī)囑信息新增服務的交易流程圖如圖2所示。圖2 醫(yī)囑信息新增服務交易流程圖醫(yī)囑信息新增服務的交易流程描述： 醫(yī)囑信息源向醫(yī)囑信息新增服務提交請求消息； 醫(yī)囑信息新增服務校驗數據并進行存儲。4.1.2 接口規(guī)范模型4.1.2.1 請求消息模型醫(yī)囑信息新

5、增服務的請求消息模型如表2所示。表2 醫(yī)囑信息新增服務請求消息模型節(jié)點基數可選項節(jié)點說明對應數據元標識符/格式要求/id/extension1.1R消息ID字符串，最大長度為50/id/root1.1R固定值"2.16.156.10011.2.5.1.1"（表示消息標識的OID編碼）/creationTime/value1.1R消息創(chuàng)建時間日期時間格式，DT14/controlActProcess/subject/placerGroup/author/time/value1.1R醫(yī)囑開立日期時間DE06.00.220.00/controlActProcess/subject

6、/placerGroup/author/signatureCode/code0.1O簽名編碼,固定值"S"/controlActProcess/subject/placerGroup/author/signatureText/value0.1O醫(yī)囑開立者簽名DE02.01.039.00/controlActProcess/subject/placerGroup/author/assignedEntity/id/item/extension0.1O醫(yī)務人員工號字符串，最大長度為50/controlActProcess/subject/placerGroup/author/as

7、signedEntity/id/item/root0.1O固定值"2.16.156.10011.1.4"（表示醫(yī)務人員工號的OID編碼）/controlActProcess/subject/placerGroup/author/assignedEntity/assignedPerson/name/item/part/value0.1O醫(yī)囑開立者DE02.01.039.00/controlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/id/item/extension0

8、.1O醫(yī)療衛(wèi)生機構（科室）ID字符串，最大長度為50/controlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/id/item/root0.1O固定值"2.16.156.10011.1.26"（表示科室號標識OID編碼）/controlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/name/item/part/value0.1O醫(yī)囑開立科室DE08.10.02

9、6.00/controlActProcess/subject/placerGroup/verifier/time/value0.1O醫(yī)囑審核日期時間DE09.00.088.00substanceAdministrationRequest/ verifier/ signatureText/value0.1O醫(yī)囑審核者簽名DE02.01.039.00/controlActProcess/subject/placerGroup/verifier/assignedEntity/id/item/extension0.1O醫(yī)務人員工號字符串，最大長度為50/controlActProcess/subjec

10、t/placerGroup/verifier/assignedEntity/id/item/root0.1O固定值"2.16.156.10011.1.4"（表示醫(yī)務人員工號的OID編碼）/controlActProcess/subject/placerGroup/verifier/assignedEntity/assignedPerson/name/item/part/value0.1O醫(yī)囑審核者姓名DE02.01.039.00/controlActProcess/subject/placerGroup/component21.*R醫(yī)囑信息根節(jié)點/controlActPro

11、cess/subject/placerGroup/component2/sequenceNumber/value0.1O醫(yī)囑序號數值型，最大長度為4/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/id/extension1.1R醫(yī)囑ID字符串，最大長度為50/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/id/root1.1R固定值"2.16.156.1001

12、1.1.28"（表示醫(yī)囑編號標識的OID編碼）/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/code/codeSystem0.1O固定值"2.16.156.10011.2.3.1.268"（表示醫(yī)囑項目類型代碼表（CV06.00.229）的OID編碼）/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/code/code0.1O醫(yī)囑項目類型代

13、碼DE06.00.289.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/code/displayName/value0.1O醫(yī)囑項目類型名稱/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/text/value0.1O醫(yī)囑項目內容DE06.00.288.00/controlActProcess/subject/placerGroup/component2/subst

14、anceAdministrationRequest/effectiveTime/ validTimeLow0.1O醫(yī)囑開始日期時間DE06.00.222.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/effectiveTime/ validTimeHigh0.1O醫(yī)囑結束日期時間DE06.00.219.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/effec

15、tiveTime/code/ codeSystem0.1O固定值"2.16.156.10011.2.5.1.13"（表示藥物使用頻次代碼表（CV06.00.228）的OID編碼）/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/effectiveTime/code/code0.1O醫(yī)囑執(zhí)行頻率編碼DE06.00.133.00/controlActProcess/subject/placerGroup/component2/substanceAdministrati

16、onRequest/effectiveTime/code/displayName/value0.1O醫(yī)囑執(zhí)行頻率名稱/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/routeCode/codeSystem0.1O固定值"2.16.156.10011.2.3.1.158"（表示用藥途徑代碼表（CV06.00.102）的OID編碼）/controlActProcess/subject/placerGroup/component2/substanceAdministr

17、ationRequest/routeCode/codeSystemName0.1O固定值"用藥途徑代碼表"/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/routeCode/code0.1O用藥途徑DE06.00.134.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/routeCode/displayName/value0.1O用藥途徑描述/c

18、ontrolActProcess/subject/placerGroup/component2/substanceAdministrationRequest/doseQuantity/value0.1O用藥劑量-單次DE08.50.023.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/doseQuantity/unit0.1O用藥劑量-單次用量單位DE08.50.024.00/controlActProcess/subject/placerGroup/component2/s

19、ubstanceAdministrationRequest/doseCheckQuantity/item/numerator/value0.1O藥物使用總劑量DE06.00.135.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/doseCheckQuantity/item/numerator/unit0.1O藥物使用總劑量單位字符串，最大長度為10/controlActProcess/subject/placerGroup/component2/substanceAdmini

20、strationRequest/doseCheckQuantity/item/denominator/value0.1O藥物使用總劑量天數數值型，最大長度為4/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/administrationUnitCode/codeSystem0.1O固定值"2.16.156.10011.2.3.1.211"（表示藥物劑型代碼表（CV08.50.002）的OID編碼）/controlActProcess/subject/placerG

21、roup/component2/substanceAdministrationRequest/administrationUnitCode/codeSystemName0.1O固定值"藥物劑型代碼表"/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/administrationUnitCode/code0.1O藥物劑型DE08.50.011.00/controlActProcess/subject/placerGroup/component2/substanceA

22、dministrationRequest/administrationUnitCode/displayName/value0.1O藥物劑型描述/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/manufacturedProduct/code/codeSystem0.1O固定值"2.16.156.10011.2.5.1.14"（表示藥物編碼的OID編碼）/controlActProcess/subje

23、ct/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/manufacturedProduct/code/code0.1O藥物編碼DE08.50.022.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/manufacturedProduct/name/item/part/value0.1O藥

24、物名稱/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/manufacturedProduct/asContent/containerPackagedProduct/capacityQuantity/value0.1O藥物規(guī)格DE08.50.043.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/con

25、sumable2/manufacturedProduct1/manufacturedProduct/asContent/containerPackagedProduct/capacityQuantity/unit0.1O藥物規(guī)格單位字符串，最大長度為10/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/subjectOf3/policy/code/code0.1O藥物醫(yī)保類別編碼字符串，最大長度為50/controlA

26、ctProcess/subject/placerGroup/component2/substanceAdministrationRequest/consumable2/manufacturedProduct1/subjectOf3/policy/code/displayName/value0.1O藥物醫(yī)保類別名稱字符串，最大長度為50/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/location/serviceDeliveryLocation/location/id/item/e

27、xtension0.1O執(zhí)行科室編碼DE08.10.025.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/location/serviceDeliveryLocation/location/id/item/root0.1O固定值"2.16.156.10011.1.26"（表示科室號標識的OID編碼）/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest

28、/location/serviceDeliveryLocation/location/name/item/part/value0.1O執(zhí)行科室名稱DE08.10.026.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/occurrenceOf/parentRequestReference/id/extension0.1O父醫(yī)囑ID字符串，最大長度為50/controlActProcess/subject/placerGroup/component2/substanceAdmin

29、istrationRequest/pertinentInformation/observation/value/code0.1O醫(yī)囑類別編碼DE06.00.286.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/pertinentInformation/observation/value/codeSystem0.1O固定值"2.16.156.10011.2.3.2.58"（表示醫(yī)囑類別代碼表（DE06.00.286.00）的OID編碼）/controlAct

30、Process/subject/placerGroup/component2/substanceAdministrationRequest/pertinentInformation/observation/value/displayName/value0.1O醫(yī)囑類別名稱DE06.00.286.00/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/component2/supplyRequest/quantity/value0.1O領藥量字符串，最大長度為10/controlActP

31、rocess/subject/placerGroup/component2/substanceAdministrationRequest/component2/supplyRequest/quantity/unit0.1O領藥量單位字符串，最大長度為10/controlActProcess/subject/placerGroup/component2/substanceAdministrationRequest/subjectOf6/annotation/text/value0.1O醫(yī)囑備注信息字符串，最大長度為200/controlActProcess/subject/placerGroup

32、/component2/substanceAdministrationRequest/subjectOf6/annotation/statusCode/code0.1O醫(yī)囑備注信息狀態(tài)字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/id/item/extension1.1R就診次數數值型，最大長度為3/controlActProcess/subject/placerGroup/componentOf1/encounter/id/item/root1.1R固定值"2.16.156.1001

33、1.2.5.1.8"（表示就診次數的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/id/item/extension1.1R就診流水號字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/id/item/root1.1R固定值"2.16.156.10011.2.5.1.9"（表示就診流水號的OID編碼）/controlActProcess/subject/placerGroup/com

34、ponentOf1/encounter/code/code1.1R就診類別編碼字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/code/codeSystem1.1R固定值"2.16.156.10011.2.3.1.271"（表示患者類型代碼表的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/code/displayName/value1.1R就診類別名稱字符串，最大長度為50/control

35、ActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/extension1.1R域ID字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/root1.1R固定值"2.16.156.10011.2.5.1.5"（表示域標識符的OID編碼）/controlActProcess/subject/placerGroup/componentOf

36、1/encounter/subject/patient/id/item/extension1.1R患者ID標識字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/root1.1R固定值"2.16.156.10011.2.5.1.4"（表示患者ID的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/ext

37、ension0.1O門（急）診號標識DE01.00.010.00/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/root0.1O固定值"2.16.156.10011.1.11"（表示門（急）診號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/extension0.1O住院號標識DE01.00.014.00/con

38、trolActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/id/item/root0.1O固定值"2.16.156.10011.1.12"（表示住院號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/telecom/item/value0.1O患者就醫(yī)聯(lián)系電話DE02.01.010.00/controlActProcess/subject/placerGroup/

39、componentOf1/encounter/subject/patient/patientPerson/id/item/extension0.1O患者身份證號DE02.01.030.00/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/id/item/root0.1O固定值"2.16.156.10011.1.3"（表示患者身份證號標識的OID編碼）/controlActProcess/subject/placerGroup/componen

40、tOf1/encounter/subject/patient/patientPerson/name/item/part/value1.1R患者姓名DE02.01.039.00/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/administrativeGenderCode/codeSystem0.1O固定值"2.16.156.10011.2.3.3.4"（表示生理性別代碼表（GB/T 2261.1）的OID編碼）/controlActProc

41、ess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/administrativeGenderCode/codeSystemName0.1O固定值"生理性別代碼表（GB/T 2261.1）"/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/administrativeGenderCode/code0.1O性別代碼DE02.01.040.00/c

42、ontrolActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/administrativeGenderCode/displayName/value0.1O患者性別描述/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/birthTime/value0.1O出生日期DE02.01.005.01/controlActProcess/subject/pl

43、acerGroup/componentOf1/encounter/subject/patient/patientPerson/asOtherIDs/id/itemroot="2.16.156.10011.1.2"/extension0.1O健康檔案編號DE01.00.009.00/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/asOtherIDs/id/itemroot="2.16.156.10011.1.2"/root

44、0.1O固定值"2.16.156.10011.1.2"（表示健康檔案編號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/asOtherIDs/id/item/extension0.1O健康卡號DE01.00.021.00/controlActProcess/subject/placerGroup/componentOf1/encounter/subject/patient/patientPerson/asOtherIDs/

45、id/item/root0.1O固定值"2.16.156.10011.1.19"（表示健康卡號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/location/id/item/extension0.1O病床號 DE01.00.026.00/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocat

46、ion/location/id/item/root0.1O固定值"2.16.156.10011.1.22"（表示病床號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/location/name/item/part/value0.1O病床號名稱字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/location/service

47、DeliveryLocation/location/asLocatedEntityPartOf/location/id/item/extension0.1O病房號 字符串，最大長度為50/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/location/asLocatedEntityPartOf/location/id/item/root0.1O固定值"2.16.156.10011.1.21"（表示病房號標識的OID編碼）/contro

48、lActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/location/asLocatedEntityPartOf/location/name/item/part/value0.1O病房號名稱DE01.00.019.00/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/serviceProviderOrganization/id/ite

49、m/extension0.1O科室編碼 DE08.10.025.00/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/serviceProviderOrganization/id/item/root0.1O固定值"2.16.156.10011.1.26"（表示科室號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/location/service

50、DeliveryLocation/serviceProviderOrganization/name/item/part/value0.1O科室名稱DE08.10.026.00/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/serviceProviderOrganization/asOrganizationPartOf/wholeOrganization/id/item/extension0.1O病區(qū)編碼 字符串，最大長度為50/controlActPro

51、cess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryLocation/serviceProviderOrganization/asOrganizationPartOf/wholeOrganization/id/item/root0.1O固定值"2.16.156.10011.1.27"（表示病區(qū)號標識的OID編碼）/controlActProcess/subject/placerGroup/componentOf1/encounter/location/serviceDeliveryL

52、ocation/serviceProviderOrganization/asOrganizationPartOf/wholeOrganization/name/item/part/value0.1O病區(qū)名稱DE08.10.054.004.1.2.2 響應消息模型（成功）醫(yī)囑信息新增服務的響應消息模型（成功）如表3所示。表3 醫(yī)囑信息新增服務響應消息模型（成功）節(jié)點基數可選項節(jié)點說明對應數據元標識符/格式要求/id/extension1.1R消息ID字符串，最大長度為50/id/root1.1R固定值"2.16.156.10011.2.5.1.1"（表示消息標識的OID編碼）

53、/creationTime/value1.1R消息創(chuàng)建時間日期時間格式，DT14/acknowledgement/typeCode1.1R處理結果，固定值"AA"表示成功/acknowledgement/targetMessage/id/extension1.1R請求消息ID字符串，最大長度為50/acknowledgement/targetMessage/id/root1.1R固定值"2.16.156.10011.2.5.1.1"（表示消息標識的OID編碼）/acknowledgement/acknowledgementDetail/text/valu

54、e1.1R處理結果說明字符串，最大長度為2004.1.2.3 響應消息模型（異常）醫(yī)囑信息新增服務的響應消息模型（異常）如表4所示。表4 醫(yī)囑信息新增服務響應消息模型（異常）節(jié)點基數可選項節(jié)點說明對應數據元標識符/格式要求/id/extension1.1R消息ID字符串，最大長度為50/id/root1.1R固定值"2.16.156.10011.2.5.1.1"（表示消息標識的OID編碼）/creationTime/value1.1R消息創(chuàng)建時間日期時間格式，DT14/acknowledgement/typeCode1.1R處理結果，固定值"AE"表示失

55、敗/acknowledgement/targetMessage/id/extension1.1R請求消息ID字符串，最大長度為50/acknowledgement/targetMessage/id/root1.1R固定值"2.16.156.10011.2.5.1.1"（表示消息標識的OID編碼）/acknowledgement/acknowledgementDetail/text/value1.1R處理結果說明字符串，最大長度為2004.2 醫(yī)囑信息更新服務（OrderInfoUpdate）4.2.1 角色和交易4.2.1.1 角色交易圖醫(yī)囑信息更新服務的角色交易圖如圖3所示。圖3 醫(yī)囑信息更新服務角色交易圖4.2.1.2 角色的選擇醫(yī)囑信息更新服務的角