協(xié)和醫(yī)院軟件系統(tǒng)集成解決方案檢查部分

資料版 期：2011年6 級(jí)：公開(kāi)資料資料資 態(tài)：初 討論 發(fā)協(xié)和醫(yī)院軟件系統(tǒng)集成解決方案 分）東華軟件公2011062020110620變更時(shí)變更內(nèi)人東華軟件公 ，保留一切權(quán)利 目本文檔用于規(guī)范協(xié)和醫(yī)院檢查系統(tǒng)與HIS系統(tǒng)的數(shù)據(jù)集成及業(yè)務(wù)集成。本文檔從DTHealth系統(tǒng)切業(yè)務(wù)流門(mén)診部申請(qǐng)申請(qǐng)單信更新預(yù)預(yù)取消預(yù)取消檢報(bào)告返報(bào)第瀏登申請(qǐng)就診信息更就診信預(yù)處處門(mén)診業(yè)務(wù)流報(bào)告連\動(dòng)態(tài)發(fā)布報(bào)退費(fèi)申退開(kāi)醫(yī) 后HIS將檢查申請(qǐng)給 到預(yù)約中心預(yù)約后HIS將預(yù)約信息返回給 到檢查科室登記后RIS返回登記信息給HIS主 列表HIS-HIS-HIS-HIS-HIS-HIS-HIS-住院部就就診信息更就診信申請(qǐng)單信更新預(yù)預(yù)取消預(yù)取消檢報(bào)告返報(bào)第瀏登申請(qǐng)預(yù)門(mén)診業(yè)務(wù)流開(kāi)醫(yī)報(bào)告連\動(dòng)態(tài)發(fā)布報(bào)退費(fèi)申入WebService從住院眾邦系統(tǒng)或諾金提供的WebService中調(diào)取病HL7的消息格式通過(guò)TCP/IPBizTalk進(jìn)行通訊。傳輸協(xié)議MLLPMLLP是目前HL7標(biāo)準(zhǔn)采用的標(biāo)準(zhǔn)接入規(guī)范。其定義主要包括如下幾個(gè)方面：MLLP協(xié)議采用標(biāo)準(zhǔn)的TCPTCP/IP技MLLP接口傳輸HL7ACK響應(yīng)Escape(e.g.,Field(e.g.,16(zz可選)正常文字(結(jié)束)，不轉(zhuǎn)Repetition(e.g.,Component(e.g.,ponent(e.g.,16(dd16進(jìn)制符號(hào))HL7消息規(guī)HL7v2.3.1標(biāo)準(zhǔn)消息格式。DataData Field|Encoding照不同的業(yè)務(wù)系IDNamespaceUniversalSendingNamespaceUniversal照不同的業(yè)務(wù)系IDNamespaceUniversalReceivingNamespaceUniversalDate/TimeofMessageMessageTriggerMessageMessageControlMessageProcessingProcessingProcessingSequenceDataDataEVN-EventTypeFieldA01EVN-RecordedEVN-Date/TimennedEVN-EventReasonEVN-OperatorIDFamilyEVN-EventEVN- Event 就診信息MSHDataDataPID-SetPID-PatientPatientPID-PatientID保存PID-AlternatePatientPID-PatientFamilyPID-Mather’sMaidenPID-Date/TimeofPID-F:FemaleHL7義PID-PID-StreetOtherStateorZiporPID-CountryPID-PhoneNumberPID-PhoneNumberPID-PrimaryPID-MaritalA-D-M-HL7義PID-PID-PatientAccountPID-SSN號(hào)PID-Driver’sLicensePID-Mother’sPID-EthicCodingPID- PID-PID-CodingDataDataPV1-SetPV1-PatientHL7定PV1-AssignedPatientPointeofPV1-1PV1-HL7定PV1-PV1-AttendingIDFamilyPV1-PV1-HospitalA01,A02,A15見(jiàn)HL7約定(和項(xiàng)目的約定是全部填寫(xiě)患者就診的科室名稱PV1-VIPPV1-AdmittingIDFamilyPV1-PatientPV1-號(hào)唯一標(biāo)識(shí)患者AdmitDischargeA03消息必須DataDataSetHL7定(M)過(guò)敏原代碼述/CodingAllergySeverityAllergy可填數(shù)據(jù)例：IdentificationDataDataSetDiagnosisCodingDiagnosis(M)診ICD10CodingDiagnosisDiagnosisDiagnosisOPDFMajorDiagnosticDiagnosticRelatedDRGApprovalDRGDRGGrouperReviewDRGOutlierOutlierOutlierDiagnosis0---1---the2andhigher-- DiagnosingFamily員工員工DiagnosisHL7義AttestationDataSetDatan0公司醫(yī)保填寫(xiě)醫(yī)保商 填 Organization醫(yī)保填寫(xiě)醫(yī)保商 填 填 單 InsuranceCo 填 單聯(lián)系人，可以為NULL InsuranceCoPhone 公 填 單GroupGroupInsured’sGroupEmpInsured’sGroupEmpnEffectivenExpirationAuthorizationn更新就診信息檢查申請(qǐng)MSHPIDDataDataSourceofCommentDataDataSourceofCommentDataDataSourceofCommentDataDataSourceofCommentPV1DataDataORC-OrderORC-cerOrderEntityNamespace申請(qǐng)科室ORC-FillerOrder EntityNamespace執(zhí)行科室ORC-cergroup HISEntityNamespaceOrderORC-Response OptionalORC- ORC- parent'scerParent'sfillerorder ORC-Date/TimeofORC-Entered醫(yī)囑錄入 （取消醫(yī)囑人IDFamilyIDFamilyORC-OrderingIDFamilyORC-Enterer’sPointofDataDataSetcerOrderEntityNamespace申請(qǐng)科室FillerOrderEntity該Field在ORU消息中還負(fù)有提供報(bào)告來(lái)源區(qū)分的功能Namespace執(zhí)行科室UniversalService如果一條包含多個(gè)檢查檢驗(yàn)項(xiàng)目,A+B+C的格式如果一條OBR包含多個(gè)檢查/檢驗(yàn)項(xiàng)目,采取A+B+C的格式Alternate如果一條包含多個(gè)檢查檢驗(yàn)項(xiàng)目,A+B+C的格式Alternate如果一條包含多個(gè)檢查檢驗(yàn)項(xiàng)目,A+B+C的格式Alternate1約Observation樣 ORM消息中檢查項(xiàng)目,請(qǐng)時(shí)間填寫(xiě)檢驗(yàn)項(xiàng)目, 時(shí)間填寫(xiě)ORU消息中檢查/檢驗(yàn)項(xiàng)目以報(bào)告時(shí)間填寫(xiě)Collector人IDFamilySpecimenActionDangerLab下為當(dāng)前檢查項(xiàng)目下建SpecimenSpecimenSourceName說(shuō)明樣本的收BodyOrderingFamily cer目前用來(lái)保存 DiagnosticService 目前為Reasonfor Principalresult Assistantresult DataDataSourceof項(xiàng)目代碼&名稱&Comment預(yù)約MSHDataDatacerFillerAppointmentEvent 1cerContactFillerContactFillerContactPhoneDataDataSetID-SegmentActionResourceGroupDataDataSetSegmentActionUniversalServiceStart更新預(yù)約參照預(yù)約取消預(yù)約參照預(yù)約檢查登記DataDataORC-OrderORC-Order已檢查DataDataORC-OrderORC-OrderA醫(yī)生取消檢查DataDataORC-OrderORC-Order執(zhí)行科室取消檢查DataDataORC-OrderORC-Order報(bào)告返回HL7MSH-1-FieldMSH-2-Encoding[M]為MSH-4-SendingMSH-6-Receiving 型。類 [M]’PforMSH-13-Sequence其他字段均為可選PID-1-Set[O]PIDPID-2-Patient[M]ID。門(mén)診PID-3-PatientID[M]ID列表病案其他字段均為可選[M]代 其他字段均為可選OBR-1-Set[M]OBRcerOrder[O]申請(qǐng)科室ID'+'OBR-3-FillerOrderOBR-3-1-EntityNotes:必須與文[O]執(zhí)行科室OBR-4-UniversalServiceNotes：如果需要合并成一個(gè)報(bào)告，ID應(yīng)為Notes：如果需要合并成—個(gè)報(bào)告，名稱應(yīng)為描OBX-4-3-Nameof1Notes:如果系統(tǒng)沒(méi)有單建議采用發(fā)報(bào)告時(shí)間填 OBR-9/OBR-10/OBR-11<NULL>forPhase <NULL>forPhaseOBR-16-OrderingOBR-16-1-IDOBR-16-1-Family PhoneOBR-18-cerFillerOBR-19/OBR-20/OBR-<NULL>forPhase <NULL>forPhaseOBR-24-DiagnosticSectOBR-25-ResultOBR-26/OBR-27/OBR-<NULL>forPhaseOBR-29/OBR-<NULL>forPhaseOBR-31-ReasonFor Notes: [M]Encoding [M]）[M]OBR-35toOBR-<NULL>forPhasereport可有多個(gè)OBXOBX-1-Set[M]OBXNotes:通常為’ST類型建議按照回車換行將源數(shù)據(jù)分成多個(gè)OBXOBXSTNotes:OBR相關(guān)定[M檢查項(xiàng)目報(bào)告項(xiàng)目[M][M]Samewith‘OBX-3-[M]Notes:影像診斷報(bào)告應(yīng)請(qǐng)統(tǒng)一轉(zhuǎn)換成OBX-8-AbnormalOBX-9-<NULL>forPhaseOBX-11-Observation[M]觀察結(jié)果的狀態(tài)。 ObservationNormal<NULL>forPhase OBX-15-Producer's<NULL>forPhase[M]OBX-18-Equipment[O]4.11報(bào)告已審核DataDataORC-OrderORC-Order已寫(xiě)報(bào)告(ORM^O01^DataDataORC-OrderO