DB35T 2153-2023 醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)結(jié)果互認(rèn)共享數(shù)據(jù)傳輸及應(yīng)用要求　

35RequirementsfordatatransmissionandapplicationofmutualrecognitionandshaofexaminationandinspectionresultsinmedicalinstitutionsI 3 本文件按照GB/T1.1—2020《標(biāo)準(zhǔn)化工作導(dǎo)則第1部分：標(biāo)準(zhǔn)化文件的結(jié)構(gòu)和起草規(guī)則》的規(guī)定本文件由福建省衛(wèi)生健康委員會(huì)和福建省信息化標(biāo)準(zhǔn)化技術(shù)委員會(huì)（SAFJ/TC11）歸口。本文件起草單位：福建省衛(wèi)生計(jì)生信息中心、四川大學(xué)華西廈門醫(yī)院、福建省立醫(yī)院、福建省級(jí)機(jī)關(guān)醫(yī)院、福建省電子政務(wù)建設(shè)運(yùn)營有限公司、福建省臨床檢驗(yàn)中心、智業(yè)軟件股份有限公司、福建本文件主要起草人：徐秋實(shí)、鄭加明、鄭雅卿、楊秋波、巫利榮、李仕軍、施怡、聶虎、黃慧萌、1醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)結(jié)果互認(rèn)共享數(shù)據(jù)傳輸及應(yīng)用要求本文件規(guī)定了醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)數(shù)據(jù)接入省級(jí)檢查檢驗(yàn)結(jié)果互認(rèn)共享平臺(tái)（以下簡稱“互認(rèn)共享本文件適用于醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)數(shù)據(jù)接入互認(rèn)共享平臺(tái)的設(shè)計(jì)、開發(fā)、測試、驗(yàn)收、應(yīng)用、管理下列文件中的內(nèi)容通過文中的規(guī)范性引用而構(gòu)成本文件必不可少的條款。其中，注日期的引用文件，僅該日期對應(yīng)的版本適用于本文件；不注日期的引用文件，其最新版本（包括所有的修改單）適WS218—2002衛(wèi)生機(jī)構(gòu)（組織）分類與代碼WS363.1—2011衛(wèi)生信息數(shù)據(jù)元目錄第1部分：總則檢查檢驗(yàn)結(jié)果互認(rèn)共享平臺(tái)themutualrecognitionandsharingplatform通過統(tǒng)一的檢查檢驗(yàn)互認(rèn)規(guī)范和互認(rèn)交互服務(wù)標(biāo)準(zhǔn)，匯聚全省醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)結(jié)果數(shù)據(jù)，實(shí)現(xiàn)4接入要求4.1互認(rèn)項(xiàng)目范圍全省醫(yī)療機(jī)構(gòu)檢查檢驗(yàn)結(jié)果互認(rèn)項(xiàng)目范圍按照附錄4.2數(shù)據(jù)接入方式2省數(shù)據(jù)中心數(shù)據(jù)省數(shù)據(jù)中心數(shù)據(jù)清洗專題庫業(yè)務(wù)庫互認(rèn)共享數(shù)據(jù)中心互認(rèn)共享數(shù)據(jù)中心節(jié)點(diǎn)1節(jié)點(diǎn)2上傳數(shù)據(jù)上傳數(shù)據(jù)上傳數(shù)據(jù)上傳數(shù)據(jù)加載省屬及各設(shè)區(qū)市數(shù)據(jù)中心省屬及各設(shè)區(qū)市數(shù)據(jù)中心省屬業(yè)務(wù)庫X市業(yè)務(wù)庫X市業(yè)務(wù)庫X市業(yè)務(wù)庫.數(shù)據(jù)數(shù)據(jù)上傳上傳醫(yī)療機(jī)構(gòu)醫(yī)療機(jī)構(gòu)三級(jí)醫(yī)療機(jī)構(gòu)二級(jí)醫(yī)療機(jī)構(gòu)基層醫(yī)療衛(wèi)生機(jī)構(gòu)4.3數(shù)據(jù)上傳流程a)醫(yī)療機(jī)構(gòu)實(shí)時(shí)將檢查檢驗(yàn)數(shù)據(jù)、PDF報(bào)告及醫(yī)學(xué)數(shù)字成像和通信（DigitalImagingandCommunicationinMedi4.4數(shù)據(jù)加載流程醫(yī)療機(jī)構(gòu)從互認(rèn)共享平臺(tái)調(diào)用就診患者的檢查檢驗(yàn)數(shù)據(jù)，有條件的醫(yī)療機(jī)構(gòu)采用預(yù)加載的方式將數(shù)據(jù)提前加載至前置服務(wù)器，加快檢查檢驗(yàn)數(shù)據(jù)4.5數(shù)據(jù)清洗流程4.6數(shù)據(jù)安全性要求d)所涉及的相關(guān)信息系統(tǒng)應(yīng)符合信息安全等級(jí)保護(hù)相關(guān)要求。35.1數(shù)據(jù)內(nèi)容數(shù)據(jù)內(nèi)容包括檢查數(shù)據(jù)、檢驗(yàn)數(shù)據(jù)、檢查檢驗(yàn)日報(bào)數(shù)據(jù)、近期檢查檢驗(yàn)記錄數(shù)據(jù)、互認(rèn)結(jié)果數(shù)據(jù)和引用結(jié)果數(shù)據(jù)，數(shù)據(jù)類型及表示格式應(yīng)符合WS363.1—25.2檢查數(shù)據(jù)1S否2SAN..50 是3S是4SAN..50否5SAN..36否6N否7SAN..36否8SAN..36是9SAN..50否SAN..60否SAN..18—否S否Medical_Card_NoSAN..36—是S是SAN..36否SAN..50否SAN..60否S—是NameSA..30—否S否SAN..8—否D—否Author_IdSA..30—否Author_NameSAN..30—否SA..30—否Authenticator_NameSAN..30—否SA..30—否SA..50 否SA..10否NameSA..50否SA..30—否SAN..30 否SAN..30—是4S是稱SAN..12 是SA..30 否SA..50—否SA..10否SA..50否SA..30 否SA..50—是SAN..12—否S 否SAN..100—是S—否SAN..2—否S—否N否Authenticator_Dept_CSA..50—否Authenticator_Dept_NSA..30—否Authenticator_Dept_Std_CSA..10否Authenticator_Dept_Std_NSA..50否—否D 否—是Author_DTime—否 否—否Arrive_DTime—否 否5.3檢驗(yàn)數(shù)據(jù)1S否2SAN..50—是3SAN..50否4SAN..36否5N否6SAN..36否7SAN..18—否8S否9Medical_Card_NoSAN..36 是5SAN..36否SAN..50否SAN..50—否SAN..60否SA..30—否S否SAN..8—否Author_IdSA..30 否Author_NameSAN..30—否SA..30—否 否SAN..30—否Requesting_PhysiciaSA..30—否Requesting_Physician_SAN..30—否Requesting_Physician_Dept_碼SA..30—否Requesting_Physician_Dept_SA..50—否Requesting_Physician_Std_DepSA..30否Requesting_Physician_Std_DNameSA..50否SAN..30—是S是SAN..12—是SAN..30—是SAN..20 是SAN..20—是SAN..30—是碼SA..30 否SA..50—否SA..30否SA..50否SA..30—否SA..50 是S否SAN..30否SAN..50否SAN..50 否S否SAN..100—否SAN..100 否SAN..8—是SAN..8—是6SAN..8 是Norm_Value_NotesSAN..100—是SAN..100—否SAN..128 否 否SAN..128 是S否Requesting_Physician—否 否Author_DTime—否—是Archive_DTime—否—否5.4檢查檢驗(yàn)日報(bào)數(shù)據(jù)1—否2S否3D否4SA..30否5SA..50—否6SA..30否7SA..50否8S—否9N 否5.5近期檢查檢驗(yàn)記錄數(shù)據(jù)1S否2SAN..30—否3SAN..30—否4SAN..50 否5—否6S否7 否75.6互認(rèn)結(jié)果數(shù)據(jù)1S否2SAN..50—否3SAN..36—否4SAN..30否5SAN..18—否6S否7S否8S是9 否S否SA..30—否SA..50 否SA..30否SA..50否SA..30 否SAN..30 否1S否2SAN..50—否3SAN..36—否4SAN..30—否5SAN..18 否6S否7—否8S否9SA..30—否SA..50—否SA..30否SA..50否SA..30 否SAN..30—否8接口包括檢查/檢驗(yàn)數(shù)據(jù)注冊接口、檢查/檢驗(yàn)數(shù)據(jù)作廢接口、檢查檢驗(yàn)日報(bào)上傳接口、獲取近期檢查檢驗(yàn)記錄接口、獲取近期互認(rèn)項(xiàng)目明細(xì)信息接口、互認(rèn)結(jié)果提交接口和引用結(jié)果提交接口，通過基于SOAP協(xié)議的WebService接口，以XML報(bào)文方式傳輸，表示格式應(yīng)符合WS363.1—1S2S3S4S因1S2S 3S—4S—5S—6S7SAN648S檢查檢驗(yàn)日報(bào)上傳接口參數(shù)見表9，接口中日報(bào)數(shù)據(jù)信息示例見附錄91S2S3SAN644S失敗返回：error：失敗1S2S3S4SAN645S1S2S3SAN644S1S2S3SAN644S1S2S3SAN644S失敗返回：error：失敗A.1檢查項(xiàng)目123456789a代碼參照《福建省衛(wèi)生健康委員會(huì)關(guān)于加快推進(jìn)檢查檢驗(yàn)結(jié)果互聯(lián)互通互認(rèn)工作的通知》（閩衛(wèi)醫(yī)政函〔2021〕A.2檢驗(yàn)項(xiàng)目123456789α-羥丁酸脫氫酶(α-HBDH）質(zhì)毛膜促性腺激素β(β-HCG））（）（）（a代碼參照《福建省衛(wèi)生健康委員會(huì)關(guān)于加快推進(jìn)檢查檢驗(yàn)結(jié)果互聯(lián)互通互認(rèn)工作的通知》（閩衛(wèi)醫(yī)政函〔2021〕數(shù)據(jù)字典123456a代碼參照《福建省衛(wèi)生健康委員會(huì)關(guān)于加快推進(jìn)檢查檢驗(yàn)結(jié)果互聯(lián)互通互認(rèn)工作的通知》（閩衛(wèi)醫(yī)政函〔2021〕10213249a代碼參照GB/T2261.1—12345678a表中的代碼參照WS364.3—2011身份證件類別代碼。1A012A023A034A03.015A03.026A03.037A03.048A03.059A03.06A03.07A03.08A03.09A03.10A03.11A03.12A04A04.01A04.01.01A04.01.02A04.01.03A04.02A04.03A04.04A04.04.01A04.05A04.05.01A04.06A04.06.01A04.07A04.08A04.09A04.10A05A05.01A05.02A05.04A05.05A05.06A06A06.01A06.02A06.03A06.04A06.05A06.06A07A07.01A07.02A07.03A07.04A07.05A07.06A07.07A07.08A07.09A07.10A07.11A07.12A08A08.01A08.02A08.03A08.04A08.05A08.06A09A09.01A09.02A09.03A09.04A09.05A09.06A10A11A11.01A11.02A11.03A11.04A12A12.01A12.02A12.03A12.04A12.05A12.06A13A13.01A13.02A13.03A14A15A15.01A15.02A15.03A15.04A15.05A15.06A15.07A15.08A16A16.01A16.02A16.03A16.04A16.05A16.06A16.07A17A18A19A20A21A22A23A23.01A23.02A23.03A23.04A23.05A23.06A24A25A26A27A28A30A30.01A30.02A30.03A30.04A30.05A30.06A31A32A32.01A32.02A32.03A32.04A32.05A32.06A32.07A32.08A32.09A32.10A32.11A50A50.01A50.02A50.03A50.04A50.05A50.06A50.07A50.08A50.09A50.10A50.11A50.12A50.13A50.14A50.15A50.16A50.17A50.18A51A51.01A51.02A51.03A51.04A51.05A51.06A52A69a代碼參照衛(wèi)生部關(guān)于下發(fā)《醫(yī)療機(jī)構(gòu)診療科目名錄》的通知、衛(wèi)生部關(guān)于在《醫(yī)療機(jī)構(gòu)診療科目名錄》中增加“重癥醫(yī)學(xué)科”診療科目的通知衛(wèi)醫(yī)政發(fā)〔20102111223344556677a代碼參照《福建省衛(wèi)生健康委員會(huì)關(guān)于加快推進(jìn)檢查檢驗(yàn)結(jié)果互聯(lián)互通互認(rèn)工作的通知》（閩衛(wèi)醫(yī)政函〔2021〕<?xmlversion="1.0"encodin<itemorg_code="123211G1001"apply_form_noreport_form_no="42471400729117557"patient_id="3002122797"event_tyevent_no="5618475016"patient_local_id="0207108"pacs_study_instance_uid="1.2.8680043.2.461.9888id_no="350823XXXXXXXX1234"id_type_code="01"card_no="125451822retrieve_date="2021/8/2221:01:07"class_code="MR"class_name="MR"report_titl告單"effective_dtime="2021/8/2214:46:06"confidentiality=""sex_code="2"sex_name="女"birth_date="1989/8/160:00:00"author_dtime="2021/8/2221:01:07"author_name="蔡XX"authenticaauthenticator_dtime="2021/8/230:00:00"authenticator_namparticipant_dept_code="0502"participant_dept_name="產(chǎn)前participant_dept_std_code="A05.02"participant_dept_std_name="產(chǎn)participant_id=""participant_dtime="2021/8/2214:46:06"participant_name="order_id=""order_priority=""order_priority_name=""performer_dept_coperformer_dept_name="放射科"performer_dept_std_code="A32performer_dept_std_name="放射治療專業(yè)"performer_doctor="蔡XX"performer_dtime="2021/8/2214:46:06"playing_device=""outpat_diag_name="產(chǎn)異常"patient_condition_descr=""exam_purpose=""image_descr="子宮體積增腦實(shí)質(zhì)未見明顯異常信號(hào)影，胼胝體可見，透明隔尚未融合，雙側(cè)大腦半球尚對稱，大腦皮層及皮層下尚清晰，雙側(cè)外側(cè)裂池形成，雙側(cè)大腦皮層較凹陷，見較多腦回、腦溝形成，中線結(jié)構(gòu)居中，余所示胎兒結(jié)構(gòu)未見明顯異常信號(hào)。胎盤附著于宮底及子宮后壁，未覆蓋子宮頸內(nèi)口，后壁最低點(diǎn)距恥骨聯(lián)合上緣約70mm，最厚處距母體臍水平向上垂直距離約58內(nèi)信號(hào)尚均勻，內(nèi)見少許血管流空信號(hào)，邊緣尚清晰，胎盤與子宮肌層分界尚清晰，未見明顯植入征象，周圍脂肪間隙尚清晰。臍帶繞頸2周，臍帶連接處位于母體臍平面上緣水平偏左側(cè)。子宮右側(cè)前壁可見一21mm×37mm×40mm橢圓形T2較低信號(hào)影，T1呈等信號(hào)，DWI呈較高信號(hào)，可見，母體雙側(cè)附件未見明顯異常信號(hào)。宮頸陰道未見異常。盆腔內(nèi)未見軟組織腫塊，膀胱壁光滑，膀胱壁及膀胱內(nèi)未見異常信號(hào)灶。盆腔骨質(zhì)未見異常信號(hào)。母體腰椎兩側(cè)各見一條迂曲增粗血管影，上端與腎靜脈匯合。"is_abnormal="1"conclusion="1、胎兒后顱窩囊性增大（考枕大池較可能，后顱窩蛛網(wǎng)膜囊腫待除外）,請隨診。2、臍帶繞頸2周子宮右側(cè)前壁結(jié)節(jié)影，考慮子宮肌瘤可能。5、母體兩側(cè)生殖arrive_dtime="2020/9/28:51:56"last_update_dtime="2020/9/28:51:56"data_spdf="MzQxaGpzZGZzZGZzZGtmMTMxMjMxMjMxMzI=（檢驗(yàn)報(bào)告單據(jù)pdf轉(zhuǎn)換成文件里byte[]在base64編碼）"><itemlast_update_dtime="2020/9/28:51:56"org_code="2event_no="5618475016"report_form_no="20200902G0060001"exam_sbody_part_name="胸部"exam_item_code="210303C00101"exam_item_name="胸部平recognition="1"><?xmlversion="1.0"encodin<itemorg_code="234521C1004"requreport_form_no="20200902G0030002"patient_id="4827650"event_type="1"event_no="3524063"iddocument_no="350823XXXXcard_no="12345678"class_code="11"class_name="臨檢血液"class_local_name="臨檢血液patient_gender="女"author_id="10992"author_name="蔡XX"verifier_id="10992"requesting_physician_id="5593"requesting_physicrequesting_physician_std_dept_code="A03.01"requesting_phy吸內(nèi)科"order_id="20200910212"specimen_id="421211"specimen_type_="1"source_specimen=""pperformer_dept_std_code="A30.01"performer_dept_std_name="醫(yī)學(xué)performer_doctor="蔡XX"test_device="K4500"darequesting_physician_time="2021/9/10:39:22"test_execution_Dtime="2021/9/10:50:20"author_Dtime="2021/9/10:58:10"effective_dtime="2021/9/12:50:20"archive_date="2021/9/20:50:20"last_updated_mzqxagpzzgzzzgzzzgtmmtmxmjmxmjmxmzi=（檢驗(yàn)報(bào)告單據(jù)pdf轉(zhuǎn)換成文件里byte[]在進(jìn)行base64編碼">local_sub_item_name="紅細(xì)胞平均體積"result_type="PQ"result_type_description="數(shù)值型"result="93.3"result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