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"登记患者的信息，康复治疗 ID 号，科室名称、姓名、性别、年龄、门诊病历号和（或）住院病历号，治疗方法、治疗日期时间，疗效等。" }, { "code": "C01100102", "display": "康复治疗记录", "definition": "生成康复治疗记录单。" } ] }, { "code": "C011002", "display": "透析治疗", "definition": "透析治疗", "concept": [ { "code": "C01100201", "display": "透析同意书", "definition": "告知透析目的、风险、注意事项、可能发生的并发症及预防措施等，生成知情同意书。" }, { "code": "C01100202", "display": "透析登记", "definition": "登记患者基本信息，保险属性，透析患者可能会有住院透析、门诊透析、家庭病房的多种形式等。" }, { "code": "C01100203", "display": "透析记录", "definition": "生成透析治疗记录。" } ] }, { "code": "C011003", "display": "放疗", "definition": "放疗", "concept": [ { "code": "C01100301", "display": "放疗同意书", "definition": "告知放疗手术目的、手术风险、术后注意事项、可能发生的并发症及预防措施等，生成知情同意书。" }, { "code": "C01100302", "display": "放疗登记", "definition": "登记放疗号，科室名称、患者姓名、性别、年龄、确诊诊断，门诊病历号和（或）住院病历号。登记患者治疗情况，建立放射治疗主索引和数据库。" }, { "code": "C01100303", "display": "放疗计划", "definition": "选择合理的放射方案，照射部位、剂量等。" }, { "code": "C01100304", "display": "放疗记录", "definition": "在影像检查的引导下置入放射性粒子。生成放射治疗记录。" }, { "code": "C01100305", "display": "放疗后指导", "definition": "对放疗术后可能会出现的不良反应，提供医学指导和相应的护理措施。" }, { "code": "C01100306", "display": "放疗随访", "definition": "生成随访记录。" }, { "code": "C01100307", "display": "放疗评估", "definition": "包括病例选择、治疗有效率、严重并发症、药物并发症、医疗事故发生情况、术后患者管理、患者生存质量、和病历质量等。" } ] }, { "code": "C011004", "display": "介入治疗", "definition": "介入治疗", "concept": [ { "code": "C01100401", "display": "介入治疗同意书", "definition": "告知介入治疗目的、风险、术后注意事项、可能发生的并发症及预防措施等，生成知情同意书。" }, { "code": "C01100402", "display": "介入治疗等级", "definition": "介入治疗等级" }, { "code": "C01100403", "display": "介入治疗记录", "definition": "在影像检查的引导下植入药物、支架等。生成介入治疗记录。" } ] }, { "code": "C011005", "display": "植入治疗", "definition": "植入治疗", "concept": [ { "code": "C01100501", "display": "植入治疗记录", "definition": "植入治疗记录" } ] }, { "code": "C011006", "display": "膳食治疗", "definition": "膳食治疗", "concept": [ { "code": "C01100601", "display": "膳食治疗记录", "definition": "生成膳食治疗记录单。" } ] } ] }, { "code": "C0111", "display": "输血", "definition": "输血", "concept": [ { "code": "C011101", "display": "输血治疗", "definition": "输血治疗", "concept": [ { "code": "C01110101", "display": "输血同意书", "definition": "记录临床诊断、输血目的、输血指征、拟输血成分、既往史（输血史、输血不良反应史、药物过敏史、妊娠史）、输血前有关检查结果、输血风险及可能产生的不良后果、患者签署意见并签名、医师签名并填写日期" }, { "code": "C01110102", "display": "输血申请", "definition": "输血申请" }, { "code": "C01110103", "display": "输血治疗记录", "definition": "记录输血前评估、输血性质、血型、血液成分、供血者血袋号、血量、输血后评价、输血治疗记录和过程中的反应及处理措施记录等。" } ] } ] }, { "code": "C0112", "display": "健康体检", "definition": "健康体检", "concept": [ { "code": "C011201", "display": "健康体检", "definition": "健康体检", "concept": [ { "code": "C01120101", "display": "体检登记", "definition": "登记体检服务对象的姓名、性别、年龄等基本信息及体检信息。建立体检主索引。" }, { "code": "C01120102", "display": "实验室检验记录", "definition": "是实验室出具的化验结果报告。包括测量值、正常范围、阴性阳性结果等。" }, { "code": "C01120103", "display": "影像检查记录", "definition": "是医技医生出具的影像诊断报告。记录影像所见、结果、诊断和建议。" }, { "code": "C01120104", "display": "诊断记录", "definition": "是体检医生对服务对象的诊断记录。" }, { "code": "C01120105", "display": "总检评价", "definition": "记录总检医生的总检报告内容，是评估报告的一种类型。" } ] } ] }, { "code": "C0113", "display": "费用结算", "definition": "费用结算", "concept": [ { "code": "C011301", "display": "住院费用结算", "definition": "住院费用结算", "concept": [ { "code": "C01130101", "display": "住院费用结算", "definition": "为出院病人办理结帐手续。" } ] }, { "code": "C011302", "display": "体检费用结算", "definition": "体检费用结算" } ] } ] }, { "code": "C02", "display": "医院管理", "definition": "医院管理", "concept": [ { "code": "C0201", "display": "医疗管理", "definition": "医疗管理", "concept": [ { "code": "C020101", "display": "客户服务", "definition": "客户服务" }, { "code": "C020102", "display": "满意度", "definition": "满意度" }, { "code": "C020103", "display": "医疗质量管理与控制", "definition": "医疗质量管理与控制" }, { "code": "C020104", "display": "药事管理", "definition": "药事管理" }, { "code": "C020105", "display": "医院感染预防与控制", "definition": "医院感染预防与控制" }, { "code": "C020106", "display": "医疗风险管理", "definition": "医疗风险管理" }, { "code": "C020107", "display": "科研管理", "definition": "科研管理" }, { "code": "C020108", "display": "培训管理", "definition": "培训管理" }, { "code": "C020109", "display": "设备质控", "definition": "设备质控" }, { "code": "C020110", "display": "膳食管理", "definition": "膳食管理" }, { "code": "C020111", "display": "病案管理", "definition": "病案管理" } ] }, { "code": "C0202", "display": "人力资源管理", "definition": "人力资源管理", "concept": [ { "code": "C020201", "display": "组织管理", "definition": "组织管理", "concept": [ { "code": "C02020101", "display": "床位", "definition": "床位" }, { "code": "C02020102", "display": "病房", "definition": "病房" }, { "code": "C02020103", "display": "科室", "definition": "科室" }, { "code": "C02020104", "display": "病区", "definition": "病区" }, { "code": "C02020105", "display": "院区", "definition": "院区" } ] }, { "code": "C020202", "display": "人事管理", "definition": "人事管理", "concept": [ { "code": "C02020201", "display": "医护人员", "definition": "医护人员" } ] }, { "code": "C020203", "display": "薪酬福利", "definition": "薪酬福利" }, { "code": "C020204", "display": "考勤管理", "definition": "考勤管理" }, { "code": "C020205", "display": "执业资质管理", "definition": "执业资质管理" }, { "code": "C020206", "display": "绩效考核", "definition": "绩效考核" } ] }, { "code": "C0203", "display": "财务管理", "definition": "财务管理", "concept": [ { "code": "C020301", "display": "预算与支出管理", "definition": "预算与支出管理" }, { "code": "C020302", "display": "账务管理", "definition": "账务管理" }, { "code": "C020303", "display": "收费管理", "definition": "收费管理" }, { "code": "C020304", "display": "价表管理", "definition": "价表管理" }, { "code": "C020305", "display": "成本核算", "definition": "成本核算" } ] }, { "code": "C0204", "display": "物资及后勤服务管理", "definition": "物资及后勤服务管理", "concept": [ { "code": "C020401", "display": "药品管理", "definition": "药品管理" }, { "code": "C020402", "display": "卫生材料管理", "definition": "卫生材料管理" }, { "code": "C020403", "display": "固定资产", "definition": "固定资产" }, { "code": "C020404", "display": "后勤管理", "definition": "后勤管理" } ] } ] } ] }