医院信息平台交互标准 第8部分：医嘱信息交互服务.docx

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1、ICS11.020CCSC07WS中华人民共和国卫生行业标准WS/T846.82024医院信息平台交互标准第8部分：医嘱信息交互服务Hospitalinformationplatforminteractivestandard一Part8：Orderinformationinteractiveservices20241028发布20250401实施中华人民共和国国家卫生健康委员会发布本标准是WS/T846医院信息平台交互标准的第8部分。WS/T846已经发布以下部分： 第1部分：总则 第2部分：个人信息注册、查询服务； 第3部分：医疗卫生机构注册、查询服务； 第4部分：医疗卫生人员注册、查询服务

2、 第5部分：术语注册、查询服务； 第6部分：文档注册、查询服务； 第7部分：就诊信息交互服务； 第8部分：医嘱信息交互服务； 第9部分：申请单信息交互服务； 第10部分：预约信息交互服务； 第11部分：状态信息交互服务。本标准由国家卫生健康标准委员会卫生健康信息标准专业委员会负责技术审查和技术咨询，由国家卫生健康委统计信息中心负责协调性和格式审查，由国家卫生健康委规划发展与信息化司负责业务管理、法规司负责统筹管理。本标准主要起草单位：国家卫生健康委统计信息中心、重庆大学、大连大学附属中山医院、国家电子计算机质量检验检测中心。本标准主要起草人：董方杰、李岳峰、张翔、郑良、钟代笛、刁晓东。医院信

3、息平台交互标准第8部分：医嘱信息交互服务1范围本标准规定了医嘱信息交互服务消息的模板、消息架构的要求以及对消息内容的约束。本标准适用于医嘱信息交互服务的应用。2规范性引用文件下列文件中的内容通过文中的规范性引用而构成本标准必不可少的条款。其中，注日期的引用文件，仅该日期对应的版本适用于本标准；不注日期的引用文件，其最新版本(包括所有的修改单)适用于本标准。GB/T2261.1个人基本信息分类与代码第1部分：人的性别代码WS/T445(所有部分)电子病历基本数据集WS/T846.1医院信息平台交互标准第1部分：总则3术语和定义WS/T846.1中界定的术语和定义均适用于本标准。4交互服务4.1医

4、嘱信息新增服务(OrderInfoAdd)4.1.1角色和交易4.1.1.1角色交易图医嘱信息新增服务的角色交易图如.所示。医嘱信息新增服务OrderInfoAdd医嘱信息新增医嘱信息源图1医嘱信息新增服务角色交易图4.1.1.2角色的选择医嘱信息新增服务的角色列表如表1所示。表1医嘱信息新增服务角色列表角色交易选择医嘱信息源医嘱信息新增必选项(R)医嘱信息新增服务医嘱信息新增必选项(R)4.1.1.3交易流程医嘱信息新增服务的交易流程图如图2所示。医嘱信息源医嘱信息新增服务图2医嘱信息新增服务交易流程图医嘱信息新增服务的交易流程描述： 医嘱信息源向医嘱信息新增服务提交请求消息； 医嘱信息新增

5、服务校验数据并进行存储，新增成功时返回成功响应消息; 医嘱信息新增服务新增失败时返回异常响应消息。4. 1.2接口规范模型5. 1.2.1请求消息模型医嘱信息新增服务的请求消息模型如表2所示。表2医嘱信息新增服务请求消息模型节点基数可选项节点说明对应数据元标识符/格式要求/id/extension1.1R消息流水号字符串，最大长度为50id(g)root1.1R固定值216.156.10011.251.LZcreationTime/value1.1R消息创建时间日期时间格式，DT15/ControlActProcess/subjectplacerGroupauthortimevalue1.1R

6、医嘱开立日期时间DE08.50.033.00controlActProcesssubjectplacerGroupauthorsignatureCode/code0.1O签名编码,固定值“S”/ControlActProcess/subject/placerGroup/author/signatureText/value0.1O医嘱开立医师签名DE02.01.039.00/ControlActProcess/subject/placerGroup/author/assignedEntity/id/item/extension0.1O医嘱开立医师工号字符串，最大长度为50/ControlActP

7、rocess/subject/placerGroup/author/assignedEntity/id/item/root0.1O固定值216.156.10011.1.4/ControlActProcess/subject/placerGroup/author/assignedEntity/assignedPerson/name/item/part/value0.1O医嘱开立医师姓名DE02.01.039.00/ControlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/id/item/

8、extension0.1O医嘱开立科室编码字符串，最大长度为50/ControlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/id/item/root0.1OH2.16.156.10011.1.26/ControlActProcess/subject/placerGroup/author/assignedEntity/representedOrganization/name/item/part/value0.1O医嘱开立科室名称DE08.10.026.00/ControlActProce

9、ss/subjectplacerGroupverifiertimevalue0.1O医嘱审核日期时间DE06.00.504.00SubstanceAdministrationRequest/verifier/SignatureText/value0.1O医嘱审核医师签名DE02.01.039.00/ControlActProcess/subject/placerGroup/verifier/assig0.1O医嘱审核医师工号字符串，最大长度节点基数可选项节点说明对应数据元标识符/格式要求nedEntity/id/item/extension为50/ControlActProcess/subje

10、ct/placerGroup/verifier/assignedEntity/id/item/root0.1O固定值216.156.10011.1.4”controlActProcesssubjectplacerGroupverifierassignedEntity/assignedPerson/name/item/part/value0.1O医嘱审核医师姓名DE02.01.039.00controlActProcesssubjectplacerGroupcomponent21.*R医嘱信息根节点/ControlActProcesssubjectplacerGroupcomponent2seq

11、uenceNumber/value0.1O医嘱序号数值型，最大长度为4/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/id/extension1.1R医嘱编号字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2SUbStanCeAdminiStratiOnReqUeSt/id/root1.1R固定值216.156.100111.28/ControlActProcesssubjectplacerGroupcomponent2SUb

12、StanCeAdminiStratiOnReqUeSt/code/cOdeSyStem0.1O固定值2.16.156.10011.2.3.1.268/ControlActProcesssubjectplacerGroupcomponent2SUbStanCeAdminiStratiOnReqUeSt/code/cOdeSyStemName0.1O固定值”医嘱项目类型代码表”/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/code/code0.1O医嘱项目类型代码DE06.00.289.00

13、/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestcodedisplayNamevalue0.1O医嘱项目类型名称/ControlActProcesssubjectplacerGroupcomponent2SUbStanCeAdminiStratiOnReqUeSt/text/VaIUe0.1O医嘱项目内容DE06.00.288.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/effe

14、ctiveTime/ValidTimeLow0.1O医嘱开始日期时间DE06.00.220.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/effectiveTime/ValidTimeHigh0.1O医嘱结束日期时间DE06.00.219.00/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZeffectiveTimeZcode/codeSystem0.1O固定值2.16.156.

15、10011.2.5.1.13/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZeffectiveTimeZcode/CodeSystemName0.1O固定值”药物使用频次代码表”/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZeffectiveTimeZcode/code0.1O药物使用频次代码DE06.00.133.00/ControlActProcesssubjectplacerG

16、roupcomponent2SubstanceAdministrationRequestZeffectiveTimeZcode/displayName/value0.1O药物使用频次名称字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/routeCode/codeSystem0.1O固定值2.16.156.10011.2.3.1.158/ControlActProcesssubjectplacerGroupcomponent2substanceAdministratio

17、nRequest/routeCode/codeSyStemName0.1O固定值”用药途径代码表”/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/routeCode/code0.1O药物使用途径代码DE06.00.134.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/routeCode/displayName/value0.1O药物使用途径描述字符串，最大长度为50/Contro

18、lActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/doseQuantity/value0.1O药物使用次剂量DE08.50.023.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/doseQuantity/unit0.1O药物使用剂量单位DE08.50.024.00/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdmmistratio

19、nRequestZdoseCheckQuantity/0.1O药物使用总剂量DE06.00.135.00节点基数可选项节点说明对应数据元标识符/格式要求item/numerator/value/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZdoseCheckQuantity/itemnumerator(g)unit0.1O药物使用总剂量单位字符串，最大长度为10/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministra

20、tionRequestZdoseCheckQuantity/item/denominator/value0.1O药物使用总剂量天数数值型，最大长度为4/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdmmistrationRequestZadministrationUnitCode/codeSystem0.1O固定值2.16.156.10011.2.3.1.211/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZadminist

21、rationUnitCode/codeSystemName0.1O固定值”药物剂型代码表”/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZadministrationUnitCode/code0.1O药品剂型代码DE08.50.011.00/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdmmistrationRequestZadmmistrationUnitCode/displayName/value0.1O药品剂型描述字符

22、串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProductl/manufacturedProduct/code/codeSystem0.1O固定值2.16.156.10011.2.5.1.14/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProductl/manufactur

23、edProduct/code/code0.1O药物编码字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProductl/manufacturedProduct/name/item/part/value0.1O药物名称DE08.50.022.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manuf

24、acturedProduct1manufacturedProductasContentcontainerPackagedProduct/capacityQuantity/value0.1O药物规格DE08.50.043.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProduct1manufacturedProductasContentcontainerPackagedProduct/capacityQuantity/unit0.1O药物规

25、格单位字符串，最大长度为10/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProductl/subjectOf3/policy/code/code0.1O药物医保类别编码字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestconsumable2manufacturedProduct1subjectOf3policycoded

26、isplayName/value0.1O药物医保类别名称字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2SUbStanCeAdminiStrationReqUeSt/IocationZserviceDeliveryLocationlocationiditem(g)extension0.1O执行科室编码字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/location/serviceDeliveryLoca

27、tionlocationiditem(g)root0.1OH2.16.156.10011.1.26/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequest/location/serviceDeliveryLocation/location/name/item/part/value0.1O执行科室名称DE08.10.026.00/ControlActProcesssubjectplacerGroupcomponent2SUbStanCeAdminiStratiOnReqUeSt/OccurrenceO

28、VparentRequestReference/id/extension0.1O父医嘱编码字符串，最大长度为50/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdmmistrationRequestZpertmentInformation/observation/value/code0.1O医嘱类别代码DE06.00.286.00/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdministrationRequestZpertinentInformatio0.1O固定

29、值节点基数可选项节点说明对应数据元标识符/格式要求n/observation/value/codeSystem2.16.156.10011.2.3.2.58/ControlActProcesssubjectplacerGroupcomponent2SubstanceAdmmistrationRequestZpertinentInformation/observation/value/displayName/value0.1O医嘱类别代码DE06.00.286.00/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrat

30、ionRequestcomponent2supplyRequest/quantity/value0.1O领药量字符串，最大长度为10/ControlActProcesssubjectplacerGroupcomponent2substanceAdministrationRequestcomponent2supplyRequest/quantity/unit0.1O领药量单位字符串，最大长度为10/ControlActProcesssubjectplacerGroupcomponent2subStanceAdministrationRequestZsubjectf6annotation/text

31、/value0.1O医嘱备注信息字符串，最大长度为200/ControlActProcesssubjectplacerGroupcomponent2subStanceAdministrationRequestZsubjectf6annotation/statusCode/code0.1O医嘱备注信息状态字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOfl/encounter/id/item/extension1.1R就诊次数数值型，最大长度为3controlActProcesssubjectplacerGroupcomponent

32、Oflencounteriditem(g)root1.1R固定值”2.16.156.10011.2.5.1.8controlActProcesssubjectplacerGroupcomponentOfl/encounter/id/item/extension1.1R就诊流水号字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOflencounteriditem(g)root1.1R固定值”2.16.156.10011.2.5.1.9controlActProcesssubjectplacerGroupcomponentOfl/enc

33、ounter/code/code1.1R患者类型代码DE02.01.060.00controlActProcesssubjectplacerGroupcomponentOfl/encounter/code/codeSystem1.1R固定值2.16.156.10011.2.3.1.271controlActProcesssubjectplacerGroupcomponentOflencountercodedisplayName/value1.1R患者类型名称字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOflencountersu

34、bjectpatientiditem(g)extension1.1R患者编号字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/id/item/root1.1R固定值216.156.10011.2.5.1.4controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/id/item/extension0.1O门(急)诊号DEOl.00.010.00controlActProcesssubje

35、ctplacerGroupcomponentOflencountersubjectpatientiditem(g)root0.1O固定值216.156.10011.l.11controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/id/item/extension0.1O住院号DEOl.00.014.00controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientiditem(g)root0.1O固定值216.156.1001

36、1.1.12controlActProcesssubjectplacerGroupcomponentOflencountersubject/patient/telecom/item/value0.1O患者电话号码DE02.01.010.05controlActProcesssubjectplacerGroupcomponentOflencountersubject/patient/patientPerson/id/item/eXtension0.1O患者身份证件号码DE02.01.030.02controlActProcesssubjectplacerGroupcomponentOflenco

37、untersubjectpatientpatientPersoniditem(g)rOOt0.1O固定值216.156.10011.1.3controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/patientPerson/name/itempart(g)value1.1R患者姓名DE02.01.039.01controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/patientPerson/administrati

38、veGenderCode/codeSystem0.1O固定值216.156.10011.2.334”controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/patientPerson/administrativeGenderCode/codeSystemName0.1O固定值”生理性别代码表(GB/T2261.1)节点基数可选项节点说明对应数据元标识符/格式要求controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patien

39、t/patientPerson/administrativeGenderCode/code0.1O患者性别代码DE02.01.040.00controlActProcesssubjectplacerGroupcomponentOfl/encounter/subject/patient/patientPerson/administrativeGenderCode/displayName/value0.1O患者性别描述字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientpatientPer

40、sonbirthTimevalue0.1O患者出生日期DE02.01.005.00controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientpatientPersonasOtherIDs/id/itemroot=2.16.156.10011.1.2/extension0.1O健康档案编号DEOL00.009.00controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientpatientPersonasOtherIDs/id/itemr

41、oot=2.16.156.10011.1.2/root0.1O固定值216.156.10011.1.2controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientpatientPersonasOtherIDsiditem(g)extension0.1O居民健康卡号DEOL00.021.00controlActProcesssubjectplacerGroupcomponentOflencountersubjectpatientpatientPersonasOtherIDs/id/item/root0.1O固定值”2

42、16.156.10011.1.19controlActProcesssubjectplacerGroupcomponentOfl/encounter/location/serviceDeliveryLocation/location/id/item/extension0.1O病床号DEOL00.026.00controlActProcesssubjectplacerGroupcomponentOfl/encounter/location/serviceDeliveryLocation/location/id/item/root0.1O固定值216.156.10011.1.22controlA

43、ctProcesssubjectplacerGroupcomponentOfl/encounter/location/serviceDeliveryLocation/location/name/item/part/value0.1O病床号名称字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOfl/encounter/location/serviceDeliveryLocation/location/asLocatedEntityPartOflocation/id/item/extension0.1O病房号字符串，最大长度为50controlActProcesssubjectplacerGroupcomponentOfl/encounter/location/serviceDeliveryLocation/locationasLocatedEntityPartOflocationiditem(g)ro