电子病历共享文档样例.rar

<?xml version="1.0" encoding="UTF-8"?> <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 ..\sdschemas\SDA.xsd"> <!-- ******************************************************** CDA Header ******************************************************** --> <realmCode code="CN"/> <typeId root="2.16.840.1.113883.1.3" extension="POCD_MT000040"/> <templateId root="2.16.156.10011.2.1.1.53"/> <!-- 文档流水号 --> <id root="2.16.156.10011.1.1" extension="RN001"/> <code code="C0033" codeSystem="2.16.156.10011.2.4" codeSystemName="卫生信息共享文档规范编码体系"/> <title>中医住院病案首页</title> <!-- 文档机器生成时间 --> <effectiveTime value="20131011054136"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="正常访问保密级别"/> <languageCode code="zh-CN"/> <setId/> <versionNumber/> <!--文档记录对象（患者） [1..*] contextControlCode="OP"表示本信息可以被重载--> <recordTarget typeCode="RCT" contextControlCode="OP"> <patientRole classCode="PAT"> <!--健康卡号--> <id root="2.16.156.10011.1.19" extension="MS201102113366666"/> <!--住院号标识--> <id root="2.16.156.10011.1.12" extension="0201306070"/> <!--病案号标识--> <id root="2.16.156.10011.1.13" extension="0201306070"/> <!--病理号标识-置于病理诊断地方> <id root="2.16.156.10011.1.8" extension="20132713"/--> <!-- 现住址 --> <addr use="H"> <houseNumber>曹张新村498-302</houseNumber> <streetName>曹张新村498-302</streetName> <township>曹张新村498-302</township> <county>曹张新村498-302</county> <city>无锡</city> <state>无锡</state> <postalCode>214000</postalCode> </addr> <telecom value="82739063"/> <patient classCode="PSN" determinerCode="INSTANCE"> <!--患者身份证号--> <id root="2.16.156.10011.1.3" extension="420106201101011919"/> <name>柏玉荣</name> <administrativeGenderCode code="1" codeSystem="2.16.156.10011.2.3.3.4" codeSystemName="生理性别代码表(GB/T 2261.1)" displayName="男性"/> <birthTime value="19330624"/> <maritalStatusCode code="20" displayName="已婚" codeSystem="2.16.156.10011.2.3.3.5" codeSystemName="婚姻状况代码表(GB/T 2261.2)"/> <ethnicGroupCode code="01" displayName="汉族" codeSystem="2.16.156.10011.2.3.3.3" codeSystemName="民族类别代码表(GB 3304)"/> <!-- 出生地 --> <birthplace> <place classCode="PLC" determinerCode="INSTANCE"> <addr> <county>无</county> <city>无锡</city> <state>无锡</state> <postalCode>214000</postalCode> </addr> </place> </birthplace> <!-- 国籍 --> <nationality code="156" codeSystem="2.16.156.10011.2.3.3.1" codeSystemName="世界各国和地区名称代码(GB/T 2659)" displayName="中国"/> <age unit="岁" value="25"></age> <!-- 工作单位 --> <employerOrganization> <name>无锡市中医院</name> <telecom value="010-99999999"/> <!-- 工作地址 --> <addr use="WP"> <houseNumber>曹张新村498-302</houseNumber> <streetName>曹张新村498-302</streetName> <township>曹张新村498-302</township> <county>曹张新村498-302</county> <city>无锡</city> <state>无锡</state> <postalCode>214000</postalCode> </addr> </employerOrganization> <!-- 户口信息 --> <household> <place classCode="PLC" determinerCode="INSTANCE"> <addr> <houseNumber>曹张新村498-302</houseNumber> <streetName>曹张新村498-302</streetName> <township>曹张新村498-302</township> <county>曹张新村498-302</county> <city>无锡</city> <state>无锡</state> <postalCode>214000</postalCode> </addr> </place> </household> <!-- 籍贯信息 --> <nativePlace> <place classCode="PLC" determinerCode="INSTANCE"> <addr> <city>无锡</city> <state>无锡</state> </addr> </place> </nativePlace> <!--职业状况--> <occupation> <occupationCode code="17" codeSystem="2.16.156.10011.2.3.3.13" codeSystemName="从业状况(个人身体)代码表(GB/T 2261.4)" displayName="职员"/> </occupation> </patient> <!--提供患者服务机构--> <providerOrganization classCode="ORG" determinerCode="INSTANCE"> <!--机构标识号--> <id root="2.16.156.10011.1.5" extension="46628604-7"/> <!--住院机构名称--> <name>无锡市中医医院</name> </providerOrganization> </patientRole> </recordTarget> <!-- 文档创作者 --> <author typeCode="AUT" contextControlCode="OP"> <time value="20130528000000"/> <assignedAuthor classCode="ASSIGNED"> <id root="2.16.156.10011.1.7" extension="002250"/> <assignedPerson> <name>李小军</name> </assignedPerson> </assignedAuthor> </author> <!-- 保管机构 --> <custodian typeCode="CST"> <assignedCustodian classCode="ASSIGNED"> <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="2.16.156.10011.1.5" extension="46628604-7"/> <name>无锡市中医医院</name> </representedCustodianOrganization> </assignedCustodian> </custodian> <!-- 科主任签名 --> <legalAuthenticator> <time/> <signatureCode/> <assignedEntity> <id root="2.16.156.10011.1.4" extension="002242"/> <code displayName="科主任"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name>陈剑峰</name> </assignedPerson> </assignedEntity> </legalAuthenticator> <!-- 主(副主)任医师签名 --> <authenticator> <time/> <signatureCode/> <assignedEntity> <id root="2.16.156.10011.1.4" extension="002242"/> <code displayName="主任(副主任)医师"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name>陈剑峰</name> </assignedPerson> </assignedEntity> </authenticator> <!-- 主治医师签名 --> <authenticator> <time/> <signatureCode/> <assignedEntity> <id root="2.16.156.10011.1.4" extension="002250"/> <code displayName="主治医师"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name>李小军</name> </assignedPerson> </assignedEntity> </authenticator> <!-- 住院医师签名 --> <authenticator> <time/> <signatureCode/> <assignedEntity> <id root="2.16.156.10011.1.4" extension="002250"/> <code displayName="住院医师"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name>李小军</name> </assignedPerson> </assignedEntity> </authenticator> <!-- 责任护士签名 --> <authenticator> <time/> <signatureCode/> <assignedEntity> <id root="2.16.156.10011.1.4" extension="003100"/> <code displayName="责任护士"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name>冯卫华</name> </assignedPerson> </assignedEntity> </authenticator> <!-- 进修医师签名 --> <authenticator>