T/SHIA 5.5—2017
目 录
前 言 ......................................................................................................................................................................... i
1 编写说明 ................................................................................................................................................................ 3
1.1 编制背景 ................................................................................................................................................ 3
1.2 应用说明 ................................................................................................................................................ 3
1.3 内容说明 ................................................................................................................................................ 3
1.4 版本说明 ................................................................................................................................................ 4
2 病历概要 ................................................................................................................................................................ 5
2.1 病历概要(C0001) .................................................................................................................................... 5
2.2 既住史（11348-0） ............................................................................................................................... 6
2.2.1 疾病史 ............................................................................................................................................ 6
2.2.2 传染病史 ........................................................................................................................................ 6
2.2.3 手术史 ............................................................................................................................................ 6
2.2.4 婚育史 ............................................................................................................................................ 6
2.3 输血史（56836-0） ............................................................................................................................... 6
2.4 过敏史（48765-2） ............................................................................................................................... 7
2.5 预防接种史（11369-6） ....................................................................................................................... 7
2.6 家族史（10157-6） ............................................................................................................................... 7
2.7 卫生事件(卫生事件) .............................................................................................................................. 7
2.7.1 用药 ................................................................................................................................................ 7
2.7.2 手术操作 ........................................................................................................................................ 7
2.7.3 西医诊断 ........................................................................................................................................ 7
2.7.4 中医诊断 ........................................................................................................................................ 7
3 门(急)诊病历 .......................................................................................................................................................... 8
3.1 门(急)诊病历（C0002） ........................................................................................................................ 8
3.2 诊断(29548-5) ........................................................................................................................................ 8
3.3 实验室检查（30954-2） ....................................................................................................................... 9
3.4 医嘱（46209-3） ................................................................................................................................... 9
4 急诊留观病历 ........................................................................................................................................................ 9
4.1 急诊留观病历（C0003） ...................................................................................................................... 9
4.2 诊断(29548-5) ...................................................................................................................................... 10
4.3 实验室检查（46209-3） ..................................................................................................................... 11
4.4 医嘱（30954-2） ................................................................................................................................. 11
4.5 手术操作(47519-4) .............................................................................................................................. 11
4.6 抢救记录(抢救记录) ............................................................................................................................ 11
5 西药处方 .............................................................................................................................................................. 13
5.1 西药处方（C0004） ............................................................................................................................ 13
5.2 诊断记录（29548-5） ......................................................................................................................... 13
5.3 用药（10160-0） ................................................................................................................................. 13
6 中药处方 .............................................................................................................................................................. 14
6.1 中药处方（C0005） ............................................................................................................................ 14
6.2 用药（10160-0） ................................................................................................................................. 14
6.2.1 中药处主用药 .............................................................................................................................. 14
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