医院信息平台医嘱信息交互服务消息示例.docx

附录A医嘱信息交互服务消息示例医嘱信息新增服务A.1.1医嘱信息新增服务.请求消息<POORJN200901UVITSVersion=nXMLeLOnxmlns=nurn:hl7-org:v3HXrnlns:xsi="http:WWW.w3.org/2001/XMLSchema-instance"xsi:schemaLocation=Hurn:hl7-org:v3./multicacheschemas/POOR_IN2(X)901UV.xsd><!-消息流水号-><idroot=,2.16.156.10011.2.5.1.1extension="(0)BS004,7><!-消息创建时间-><creationTimevalue=",201201061100007><!-消息的服务标识-><interactionldroot=,2.16.156.10011.2.5.1.2hextension=POORJN200901UV7><!-处理代码，标识此消息是否是产品、训练、调试系统的一部分。D：调试：P：产品：T：训练><processingCodecode=nP,7><!消息处理模式:A(Archive);!(Initialload);R(Restorefromarchive);T(Currentprocessing)"><processingModeCode><!消息应答：AL(AIways);ER(Errorrejectonly);NE(Never)><acceptAckCodecode=,AL,7><!一接受者一><receivertypeCode=nRCVn><deviceClassCode=nDEVndeterminerCode=INSTANCE,><!-接受者ID<id><itemroot=,2.16.156.10011.2.5.1.3extension=nlI7><id><device><receiver><!-发送者-><sendertypeCode=nSND><deviceClassCode=nDEVndeterminerCode=,INSTANCE,><!-发送者ID-><id><itemroot=H2.16.156.1(X)11.2.5.1.3Hextension=H222V><id><device><sender><controlActProcessClassCode=nCACTnmoodCode=,EVN,><subjecttypeCode=,SUBJ,><placerGroupClassCode=nGROUPERnmoodCode=nRQO><!-医嘱开立者-><authortypeCode=nAUTcontextControlCode=,OP,><!-医嘱开立日期时间<timevalue=20120202030303,7><!-签名编码(固定值S)<signatureCodecode=S,7><!医嘱开立者签名><signatureTextValUe="李医生,7><assignedEntityclassCode=,ASSIGNED,><!”医务人员一号<id><itemroot=,2J6.156.1001l.L4,textension=11120109197706015518,7><id>OssignedPersonClassCode=nPSNndeterminerCode=nINSTANCEH><!-医嘱开立者<namexsirtype=BAGEN><item><partVallle="李医生"/><item><name><assignedPerson><representedrganizationClassCode=nORGndeterminerCode=,INSTANCE><!-医疗卫生机构（科室）ID><id><itemroot=,2.16.156.10011.1.26t,extension=111234567890,7><id><!-医嘱开立科室<namexsitype=BAGENn><item><partVahle="呼吸内科"/><item><name><representedrganization><assigncdEntity><author><!医嘱审核者<verifierIypeCode=nVRFncontexlControlCode=OP,><!一医嘱审核日期时间一><limevalue=,20120202030303,7><!签名编码（固定值S）<signatureCodecode=S,7><!一医嘱审核者签名<signatureTextValUe="王医生,7>OssignedEntityClaSSeOde="ASSIGNED”,V!-医务人员工号<id><itemrt=n2.16.156.10011.1.4,texlension=120109197706015518,7><id><assignedPersonClassCode=nPSNndeterminerCode=,INSTANCE,><!医嘱审核者<namexsitype=BAGENn><item><partVaIUe="王五"/><item><name><assignedPerson><assignedEntity><verifier><component2><!一医嘱序号<sequenceNumbervalue=n7><substanceAdninistrationRequestClassCode=nSBADMnmoodCode=nRQO><!-医嘱ID-><idroot=H2J6J56J0011.L28Hextension=OBSOO7><!-医嘱项目类型代码<codecode=1,1CodeSyStem='216,156.10011.231.268''><displayNameValUe="药品类医嘱"/><code><!-医嘱项目内容<text><!一医嘱状态<statusCodeCOde="active'/<!-医嘱有效期间:医嘱开始日期时间/医嘱结束日期时间<effectiveTimexsi:type="QSCJrS”ValidTimeLoW="20110202030303,tvalidTimeHigh=20110203030303,r><!-医嘱执行频率编码/医嘱执行频率名称<codecode=,BIDcodeSystem=n2J6J56.1001L2.5.113”><dispIayNamevalue=,2/H(8am-4pm)7><code><effectiveTime><!-用药途径-><routeCodecode='”"codeSystem=n2.16.156.10011.2.3.1.158”CodeSyStemName="用药途径代码表"><displayNameVaIUe="口服"/><routeCode><!用药剂量单次-><doseQuantityvalue=,120nunil=mg,7><!.药物使用总剂量_><doseCheckQuantityxsi:type=HDSET_RTOH><item><numeratorxsirtype=,PQunit=gvalue=117><denominatorxsilye=PQunil=,d,rvalue=17><item><doseCheckQuantity>!一药物剂型一><administrationUnitCodeCOde=TCodeSyStem="2.16.156.10011.2.3.1.211”CodeSyStemName="药物剂型代码表”>VdisplayNamevalue="片剂(素片、压制片)，浸膏片,非包衣片7><administrationUnitCode><!-药物信息<consumable2typeCode=,CSM><manufacturedProduct1ClassCode=nMANU><!-包装序号<idextension=111234,7><manufacturedProductClassCode=nMMATndeterminerCode=nKIND><!-药物编码-><codeCOde="201056”codeSystem=2.16J56.10011.2.5,1.147><namexsi:type=HBAGEN,><item><!-药物名称一><partVaIUe="葡萄糖酸钙"/><item><name><asContentclassCode=,CONT,>><quantity>CcontainerPackagedProductClassCode=nHOLDndeterminerCode=nKIND><code><formCode><!-药物规格一><caacityQuantilyUniI="g片"VaIUe=<containerPackagedProduct><asContent><manufacturedProduct><!-药物所属医保信息<subjectf3typeCode=nSBJ,><policyClassCode=TOLICYnmoodCode=,EVN,r><!-药物医保类别编码/药物医保类别名称<codeCode="01<displayNameVaIIIe="甲类,7><code><policy><subjectf3><manufacturedProduct1><consumable2><locationtypeCode=LOC><serviceDeliveryLocationclassCode=nDSDLOC><locationClassCode=nPLCndeterminerCode=,INSTANCE,><!执行科室编码，<id><itemroot=,2.16.156.10011.1.26extension=001,7><id><!执行科室名称><namexsi:type=HBAG_ENH><item><partValUe="呼吸内科”/><item><name><location><serviceDeliveryLocation><location><!-父医嘱ID（没有父医嘱可以没有此。CeUrrenCeO蟀点）-><occurrencef><parentRequestReferenceClaSSCode="GROUPER”,<idextension=,31657457,7><parentRequestReference><occurrencef><!-医嘱类别（I长期医嘱2临时医嘱9其他）-><pertinentlnformationtypcCode=,PERTcontextConductionInd=false><observationClassCode=nOBS”moodCode=EVN,><codeCode=''DE06XX）.28600''COdeSyStem='216.156.1001122.1"CodeSyStemName="卫生信息数据元目录”/><!医嘱类别编码/医嘱类别名称<valuexsi:type=HCDHcode=1codeSystem=2.16.156.10011.2.3.2.58,>CdispIayNameVaIlIe="长期医嘱"/><value><observation><pertinentlnformation><component2><!-领量（给药量）/领量单位（实际发药量由药房发药确定）-><supplyRequestClassCode=nSPLYnmoodCode=,RQO><id><code><statusCodccode=uactive,7><!-领药量><quantityvalue=,UnitF胶囊V><!-开始时间/停止时间（可以都没有值）-><expectedUseTimevalidTimeLow=,2（）l11231IOlOnvalidTimeHigh=n7><supplyRequest><component2><!-医嘱备注信息<subjectf6typeCode=nSUBJcontextConductionInd=,false,><seperatablelndvalue=nfalse,7><annotation><!-医嘱备注信息textvalue=”对下达医嘱的补充说明和注意事项提示”/><staiusCodecode=ncompleted,7><author><assignedEntityCIaSSCode="ASSIGNED'/<author><annotation><subjectf6><substanceAdministrationRequest><component2><!一就医信息<componentflConteXtConduCtiOnInd="false”><encounterClaSSCode="ENC"moodCode=EVN,r><id><!-就诊次数<iternextension=,2root=2.16.156.1OOl1.2.5.1.8,7><itemextension=123456root=2.16.156.10011.2.5.1.97><id><!-就诊类别编码<codecodeSystem=,-2.16.156.1OO11.23.1.271,code=0,><!-就诊类别名称-><displayNamevalue=11诊/住院/体检”/><code><statusCodeCOde="active”/<subjecltypeCode=,SBJ><patientclassCode=nPAT,><id><!-域ID-><itemroot=,2.16.156.10011.2.5.1.5extension=,l07><!-患者ID标识<itemroot=2.16.156.1(X)11.2.5.1.4extension=,HA201102113366666,7><!-门(急)诊号标识-><itemrt=,2.16.156.10011.1.10,textension="ElOooooo(T7><!-住院号标识<itemroot=2.16.156J001LL12,textension=HA2011021133666667><id><!-患者就医联系电话<telecomxsirtype=,BAGTEL,><itemvalue=,l3578945678,7><telecom><!-患者角色状态<statusCodecode=,active,7><patientPersonClassCode=nPSNndeterminerCode=HINSTANCEH><!-患者身份证号<id><itemrool=n2.16.156.1lLI.3extension=12345678907><id><namexsi:type=MBAG_ENH><item><partVallIe="王五"7<item><name><!-性别<administrativeGenderCodecode=1”CodeSyStem=216156100112334”COdeSyStemName="生理性别代码表(GB/T2261.1),r><displayNameVaIUe="男性"/><administrativeGenderCode><!-出生日期一><birthTimevalue=,195703237><asOtherIDsclassCode=HROLH><!健康档案编号<id><itemroot=2.16.15610011.1.2,textension=1112345678901234567,7><!-健康卡号<itemrt=2.16.156.10011.1.19”extension=12345678907><id>CscopingOrganizationClassCode=nORG”determinerCode=,lNSTANCEnxsirnil=true,7><asOtherIDs><patientPerson><patient><subject><!住院位置VlOCatiOnIyPeCode="LoC”><time>CserviceDeIivetyLocationclassCode=nSDLOC><locationCIaSSCode="PLC"determinerCode="INSTANCE"><!-DE01.(X).026.00病床号<id><itemroot=,2.16.156.10011.1.22ttextension=007><id><namexsi:type=MBAG_ENn><item><partVaIUe="1床”><item><name>OsLocatedEntityPartOfClassCode=llLOCE><locationCIaSSCode="PLC"determinerCode=,INSTANCE><!-DE01.00.019.00病房号-><id><itemroot=2.16.156J001LL21,textension=,1007><id><namexsi:type=HBAG_ENH><item><partvalue=1,205,7><itern><narne><location><asLocatedEntityPartOf><location><serviccProviderOrganizationClassCode=nORGndeterminerCode=nINSTANCEH><!-DE08.10.026.00科室名称-><id><itemroot=,2.16.156.10011.1.26,textension=007><id><namexsi:type=MBAG_ENn><item><partVaIUe="呼吸内科"><itern><name><asOrganizationPartOfclassCode=,PART,><!-DE()8.10.054.00病区名称>CwhoIeOrganizationClassCode=nORGndeterminerCode=INSTANCE,t><id><itemrt=n2.16.156.111.1.27,textension=,007><id><namexsilype=BAG-ENn><item><partVaIUe="呼吸科病区,7><item><narne><wholerganization><asrganizationParlOf><serviceProviderOrganization><serviceDcliveryLocation><Iocation><encounter><componentfl><pIacerGroup><subject><controlActProcess><POOR.IN200901UV>A.1.2医嘱信息新增服务-响应消息（成功）<MCCLIN()()()()()2UV()1ITSVersion+'XMLO'Xmlns:xsi="http:WWW.w3org2()()lXMLSChemainstance11xmlns=Hum:hl7-org:v3HxsizschemaLocation=,urnhl7-org:v3.multicacheschemasMCCIIN000002UVOI.xsdn><idroot=u2.16.156.10011.2.5.1.1extension=n12122,7><creationTimeVaIUe="20170106903,7><interactionldroot=n2.16.156.10011.2.5.1.2,textension=,MCCIJN000002UVO17><processingCodccode=,P,7><processingModeCode><acceptAckCodecode=nAL,7><receivertypeCode=RCV><deviceClassCode=nDEVndeterminerCode=,INSTANCE,><id><itemroot=H2.16.l56.10011.2.5.1.3extension=HlI7><id><device><receiver><sendertypeCode=nSND><deviceClassCode=nDEVndeterminerCode=,INSTANCE,><id><itemroot=H2.16.156.10011.2.5.1.3extension=()222,7><id><device><sender>CacknowIedgementtypeCode=,AA,><!一请求消息ID><targetMessage><idrt=,2J6.156J0011.2.5.L,extension="请求的消息><targetMessage><acknowledgementDetail><textVaIUe="处理结果说明"><acknowledgementDetail><acknowledgement>vMCCUN000002UVO1>A.1.3医嘱信息新增服务-响应消息(异常)<MCCIJN000002UV01ITSVersion=,XML_1.0XmIns:xsi="http:WWW.w3.org/2001/XMLSchema-instancexmlns=Hurn:hl7-org:v3nxsi:schemaLocation=Murn:hl7-org:v3.ZmulticacheschemasZMCClJN000002UVO1.xsd><idroot=2.16.156.10011.2.5.1.1hextension="®12122,7><creationTimevalue=201701061519037><interactionldroot=2.16.156.10011.2.5.1.2extension=MCCLIN0()()()()2UVO17><processingCodecode=nP,7><processingModeCode><acceptAckCodecode=,AL,7><receivertyeCode=,RCV><deviceClassCode=nDEVndeterminerCode=HINSTANCEH><id><itemrt=,2.16.156.10011.2.5.1.3ttextension=Hl17><id><device><receiver><sendertypeCode=nSND><deviceClassCode=nDEVndeterminerCode=,INSTANCE,><id><itemroot=,12.16.156.10011.2.5.1.3extension=H222*7><id><device><sender><acknowledgementtypeCode=,AE>v!-请求消息ID-><targetMessage><idrt=21615610011.25L1”extension="请求的消息、IDV>vtargetMessage><acknowlcdgemcntDetail><textVaIUe="处理结果说明"><acknowledgementDctail><acknowledgement><MCCLIN000002UV01>医喔信息更新服务A.1.4医嘱信息更新服务-请求消息<POOR_IN200902UVxmlns=Hurn:hl7-org:v3Hxmlns:xsi=Mhttp:/www.w3.org/2001XMLSchera-instanceITSVersion=nXMLeI.0xsi:schemaLocation=Hurn:hl7-org:v3.multicacheschemasPOORIN200902UV.xsdn><!-消息流水号-><idroot=,2.16.156.10011.2.5.1.1extension="(0)BS004,7><!-消息创建时间-><creationTimevalue=201201061100007><!-消息的服务标识-><interactionldroot=2.16.156.10011.2.5.1.2hextension=POORJN200902UV7><!-处理代码，标识此消息是否是产品、训练、调试系统的一部分。D：调试；P：产品；T：训练><processingCodecode=nP,7><!消息处理模式:A(Archive);!(Initialload);R(Restorefromarchive);T(Currentprocessing)><processingModeCode><!消息应答：AL(AIways);ER(Errorrejectonly);NE(Never)><acceptAckCodecode=,AL,7><!-接受者><receivertypeCode=nRCVn><deviceClassCode=nDEVndeterminerCode=HINSTANCEH><!-接受者ID<id><itemroot=,2.16.156.10011.2.5.1.3extension=nlI7><id><device><receiver><!-发送者><sendertypeCode=,SND><deviceClassCode=nDEVndeterminerCode=,INSTANCE,><!-发送者ID-><id><itemroot=H2.16.156.1(X)11.2.5.1.3Hextension=H222V><id><device><sender><controlActProcessClassCode=nCACTnmoodCode=EVN><subjecttypeCode=,SUBJ,><placerGroupClassCode=nGROUPERnmoodCode=nRQO><!-医嘱开立者-><authortypeCode=nAUTcontextControlCode=,OP,>v!-医嘱开立口期时间-><timevalue=20120202030303,7><!-签名编码(固定值S)<signatureCodecode=S,7><!-医嘱开立者签名<signatureTextValUe="李医生,7><assignedEntityclassCode=,ASSIGNED,><!”医务人员一号<id><itemroot=,2J6.156.1001l.L4,textension=11120109197706015518,7><id>VaSSignedPerSonCIaSSCOde="PSN"determinerCode="NSTANCE”><!医嘱开立者，<namexsi:type=HBAG_ENH><item><artVahIe="李医生"><item><name><assignedPerson><representedrganizationclassCode=HORGHdeterminercode="NSTANCE”>v!-医疗卫生机构（科室）ID-><id><itemroot=,2.16.156.1（X）11.1.26extension=1112345678907><id><!-医嘱开立科室<namexsi:type=HBAG_ENH><item><partVaIUe="呼吸内科"/><itern><name><reresentedrganization><assignedEntity><author><!一医嘱审核者-><verifiertypeCode=,VRFncontextControlCode=OP,>V!-医嘱审核口期时间<timevalue=20120202030303,7><!-签名编码（固定值S）<signatureCodecode=S,7><!医嘱审核者签名一><signatureTextValUe="王医生,7<assignedEntityclassCode=,ASSIGNED,><!”医务人员一号<id><itemroot=,2J6.156.1001l.L4,textension=11120109197706015518,7><id>OssignedPersonClassCode=nPSNndeterminerCode=HINSTANCEn><!-医嘱审核者<narnexsi:type=HBAG_ENH><item><partValUe="王五"/><itern><name><assignedPerson><assignedEntity><verifier><component2><!医嘱序号-><sequenceNumbervalue=,7><substanceAdministrationRequestclassCode="SBADMhmoodCode=RQO><!医嘱ID><idroot=,12.16.156J0011.1.28,textension=OBSOO17><!医嘱项目类型代码<codecode=n1,tcodeSystem=,2.16.156.10011.2.3.1.268ll><displayNameVaIUe="药品类医嘱”/><code><!一医嘱项目内容<lext><!医嘱状态USZOdeCOde“ac11ve”医嘱有效期间:医嘱开始日期时间/医嘱结束日期时间<effecliveTimexsi:type=nQSC_TSnvalidTimeLow=n20110202030303validTimeHigh=n20110203030303,t><!-医嘱执行频率编码/医嘱执行频率名称<codecode=BIDcodeSystem=1,2.16.156.10011.2.5.1.13”><dislayNamevalue=,2/日(8am-4m),7><code><effectiveTime><rouleCodecode=n1,codeSyslem=,2.16.156.10011.2.3.1.158”COdeSyStemName="用药途径代码表”><displayNarneValUe="口服'7><routeCode><!用药剂量-单次><doseQuantityVaklC="20"unit=mg,7><!-药物使用总剂量-><doseCheckQuantityxsi:type=HDSET_RTOH><item><numeratorxsilype=PQunit=gvalue=,f17><denominatorxsiztype=,PQunit=dvalue=,t7><item><doseCheckQuantity><!药物剂型一><administrationUnitCodeCode=TcodeSystem=n2.16.156.10011.2.3.1.21,CodeSyStemName="药物剂型代码表”>VdisplayNamevalue="片剂(素片、压制片)，浸膏片,非包衣片7><administrationUnitCode><!-药物信息<consumable2typeCode=nCSM,><manufacturedProduct1classCode=,MANU><!-包装序号<idextension=111234,7><manufacturcdProductClassCode=nMMATndeterminerCode=nKIND,r><!-药物编码-><codecode=n201056codeSystem=2.16.156.10011.2.5,1.147><narnexsi:type=HBAG_ENH><item><!一药物名称一><partValUe="葡萄糖酸钙<item>