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行政院衛(wèi)生署委辦計(jì)畫
臺(tái)灣醫(yī)學(xué)資訊學(xué)會(huì)製
2005.7.5
目錄
第一章 TMT 電子病歷架構(gòu)圖.............................................................................................................5
TMT 電子病歷架構(gòu)圖...................................................................................................................6
第二章 門?....................................................................................................................................7
病歷首頁(yè)單.................................................................................................................................8
西醫(yī)門詥?................................................................................................................................9
牙醫(yī)門詥?..............................................................................................................................10
中醫(yī)門詥?.............................................................................................................................. 11
中醫(yī)傷科針灸單........................................................................................................................12
第三章 急?..................................................................................................................................13
急曰舉Y料單........................................................................................................................14
急詸z傷分類單........................................................................................................................15
急勻朐河?#63807;單........................................................................................................................16
急葬t(yī)囑單...............................................................................................................................17
第四章 住院...................................................................................................................................18
住院基本資料單........................................................................................................................19
住院入院記錄單........................................................................................................................20
出院病摘單...............................................................................................................................21
病程紀(jì)錄單...............................................................................................................................22
住院醫(yī)囑單...............................................................................................................................23
會(huì)隕暾?qǐng)?..............................................................................................................................24
麻醉紀(jì)錄單...............................................................................................................................25
手術(shù)記錄單...............................................................................................................................26
中醫(yī)住院?jiǎn)?..............................................................................................................................27
第五章 護(hù)理...................................................................................................................................28
急宰o(hù)理處置單........................................................................................................................29
入院護(hù)理評(píng)估單........................................................................................................................30
生命徵象測(cè)量記錄單................................................................................................................31
護(hù)理記錄單...............................................................................................................................32
護(hù)理詳鄦?..............................................................................................................................33
護(hù)理計(jì)畫單...............................................................................................................................34
第六章 計(jì)畫申請(qǐng)............................................................................................................................35
處方箋.......................................................................................................................................36
實(shí)驗(yàn)室檢查申請(qǐng)單....................................................................................................................37
醫(yī)學(xué)影像檢查申請(qǐng)單................................................................................................................38
核子醫(yī)學(xué)檢查申請(qǐng)單................................................................................................................39
超音波檢查申請(qǐng)單....................................................................................................................40
電腦斷層掃描檢查申請(qǐng)單........................................................................................................41
心電圖檢查申請(qǐng)單....................................................................................................................42
腦波檢查申請(qǐng)單........................................................................................................................43
病理檢查申請(qǐng)單........................................................................................................................44
第七章 報(bào)告...................................................................................................................................45
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藥師調(diào)劑單...............................................................................................................................46
實(shí)驗(yàn)室檢查報(bào)告單....................................................................................................................47
放射線檢查報(bào)告單....................................................................................................................48
核子醫(yī)學(xué)檢查報(bào)告單................................................................................................................49
超音波檢查報(bào)告單....................................................................................................................50
電腦斷層掃描檢查報(bào)告單........................................................................................................51
心電圖檢查報(bào)告單....................................................................................................................52
腦波檢查報(bào)告單........................................................................................................................53
病理檢查報(bào)告單........................................................................................................................54
會(huì)詧?bào)告?..............................................................................................................................55
第八章 其他...................................................................................................................................56
營(yíng)養(yǎng)諮詢單...............................................................................................................................57
衛(wèi)教單.......................................................................................................................................58
第九章 同意書...............................................................................................................................59
手術(shù)同意書...............................................................................................................................60
麻醉同意書...............................................................................................................................61
通用同意書...............................................................................................................................62
第十章 模組...................................................................................................................................63
醫(yī)療機(jī)構(gòu)資料模組....................................................................................................................64
醫(yī)療機(jī)構(gòu)簽章模組....................................................................................................................65
各類病史模組............................................................................................................................66
常見過(guò)去病史模組....................................................................................................................67
過(guò)敏史模組...............................................................................................................................68
個(gè)人史模組...............................................................................................................................69
家族史模組...............................................................................................................................70
產(chǎn)科史模組...............................................................................................................................71
月經(jīng)史模組...............................................................................................................................72
其他病史模組............................................................................................................................73
手術(shù)及入出院索引模組............................................................................................................74
病人基本資料模組....................................................................................................................75
病人基本資料摘要模組............................................................................................................76
中醫(yī)傷科針灸計(jì)畫模組............................................................................................................77
中醫(yī)客觀模組............................................................................................................................78
急曰舉Y料摘要模組............................................................................................................79
急宰o(hù)理處置模組....................................................................................................................80
護(hù)理監(jiān)測(cè)評(píng)估模組....................................................................................................................81
護(hù)理醫(yī)療處置模組....................................................................................................................82
輸血記錄模組............................................................................................................................83
住院護(hù)理模組............................................................................................................................84
護(hù)理其他記錄模組....................................................................................................................85
院內(nèi)動(dòng)向模組............................................................................................................................86
出院時(shí)情況模組........................................................................................................................87
醫(yī)囑模組...................................................................................................................................88
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手術(shù)模組...................................................................................................................................89
主觀模組...................................................................................................................................90
客觀模組...................................................................................................................................91
理學(xué)檢查模組............................................................................................................................92
系統(tǒng)評(píng)估模組............................................................................................................................93
評(píng)估模組...................................................................................................................................94
疾病詳嗄＝M............................................................................................................................95
處置申請(qǐng)模組............................................................................................................................96
治療程序模組............................................................................................................................97
檢查項(xiàng)目模組............................................................................................................................98
開藥模組...................................................................................................................................99
報(bào)告模組.................................................................................................................................100
給藥模組.................................................................................................................................101
投保身份別模組......................................................................................................................102
急緣皆耗＝M..........................................................................................................................103
急鑰苿e模組..........................................................................................................................104
西醫(yī)科別模組..........................................................................................................................105
主訴模組.................................................................................................................................106
生命徵象模組..........................................................................................................................107
到院方式模組..........................................................................................................................108
詳?出入院史模組................................................................................................................109
表單資料模組.......................................................................................................................... 110
簽章模組................................................................................................................................. 111
醫(yī)師群組簽章模組.................................................................................................................. 112
交換模組................................................................................................................................. 113
溝通模組................................................................................................................................. 114
關(guān)聯模組................................................................................................................................. 115
價(jià)值模組................................................................................................................................. 116
選擇模組................................................................................................................................. 117
移動(dòng)模組................................................................................................................................. 118
感受模組................................................................................................................................. 119
知識模組.................................................................................................................................120
感覺模組.................................................................................................................................121
法定通報(bào)項(xiàng)目模組..................................................................................................................122
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第一章 TMT 電子病歷架 |
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