BasicdatasetsfornursingmanagementinthehospitalsofTraditionalChineseMedicine——Part3:BusinessResourceManagementofNursing中國中醫(yī)藥信息學(xué)會發(fā)布 中醫(yī)醫(yī)院護(hù)理管理信息基本數(shù)據(jù)集第3部分：護(hù)理業(yè)務(wù)資源管理GB/T17538全國干部、人事管理信息系統(tǒng)WS218衛(wèi)生機(jī)構(gòu)(組織)分類與代碼WS/T303衛(wèi)生信息數(shù)據(jù)元標(biāo)準(zhǔn)化規(guī)則WS/T304衛(wèi)生信息數(shù)據(jù)模式描述指南WS/T305衛(wèi)生信息數(shù)據(jù)集元數(shù)據(jù)規(guī)范WS/T306衛(wèi)生信息數(shù)據(jù)集分類與編碼規(guī)則WS364衛(wèi)生信息數(shù)據(jù)元值域代碼WS370衛(wèi)生信息基本數(shù)據(jù)集編制規(guī)范中醫(yī)醫(yī)院護(hù)理管理nursingmanagementforhospitalofTraditionalChineseDE數(shù)據(jù)元（DataEleme4數(shù)據(jù)集元數(shù)據(jù)屬性中醫(yī)醫(yī)院護(hù)理管理信息基本數(shù)據(jù)集第3部分:護(hù)理業(yè)務(wù)資源記錄護(hù)理業(yè)務(wù)資源管理相關(guān)信息。包括護(hù)理制度管理、護(hù)理服務(wù)管理、護(hù)理質(zhì)量管理、護(hù)理安全管理、護(hù)理教學(xué)管理、V1.05.2.2.2護(hù)理人員執(zhí)業(yè)環(huán)境測評5.2.3.4護(hù)理質(zhì)量檢查及持續(xù)改進(jìn)護(hù)理質(zhì)量檢查及持續(xù)改進(jìn)子集的數(shù)據(jù)元專用屬性描述見表9。5.2.3.6護(hù)理質(zhì)量分析會議記錄5.2.4.1護(hù)理風(fēng)險(xiǎn)上報(bào)與追蹤評價(jià)5.2.6.3護(hù)理新業(yè)務(wù)新技術(shù)管理5.2.7.1護(hù)理日常事務(wù)管理計(jì)劃與總結(jié)子集D—AN..50—AN..500—D—D—D—AN..70—D—N1..2護(hù)理服務(wù)實(shí)際感受和期望值的比值，計(jì)量單位為“%”NN..6，2—D—N1..2AN..200—護(hù)理服務(wù)實(shí)際感受和期望值的比值，計(jì)量單位為“%”NN..6，2—標(biāo)識護(hù)理人員所在工作單位科室在特定編碼體系中的代碼AN..5按照某一特定編碼規(guī)則賦予護(hù)理人員的順序號AN..10—護(hù)理人員在公安管理部門正式登記注冊的姓氏和名稱A..50—NN1..3—護(hù)理人員執(zhí)業(yè)注冊至今工作年限的數(shù)值NN..3—護(hù)理人員已取得的相關(guān)專業(yè)職稱在特定編碼體系中的代碼護(hù)理人員受教育的最高程度類別在特定編碼體系中的代碼標(biāo)識護(hù)理人員是否為事業(yè)單位編制L—進(jìn)行護(hù)理人員執(zhí)業(yè)環(huán)境測評當(dāng)日的公元紀(jì)年日期D—護(hù)理人員執(zhí)業(yè)環(huán)境測評內(nèi)容的具體描述AN..200—護(hù)理人員執(zhí)業(yè)環(huán)境測評的得分結(jié)果，計(jì)量單位為“分”NN..3—AN..5D—AN..500—AN..500—AN..5D—AN..100—護(hù)理質(zhì)量管理小組成員在公安管理部門正式登記注冊的姓氏和名稱A..50—AN..200—L—護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)名稱D—D—護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)的總標(biāo)準(zhǔn)分值，計(jì)量單位為“分”NN..3—護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)的合格分，計(jì)量單位為“分”NN..3—AN..500—護(hù)理質(zhì)量評價(jià)項(xiàng)目的權(quán)重計(jì)分值，計(jì)量單位為“分”NN..3—護(hù)理質(zhì)量評價(jià)過程中采取評價(jià)方法的具體描述，包括現(xiàn)場AN..500—AN..500—D—AN..50—AN..5護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)名稱NN..3—NN..3—A..50—D—護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)名稱AN..500—AN..500—AN..500—AN..100AN..500—AN..50D—護(hù)理質(zhì)量改進(jìn)復(fù)查者在公安管理部門正式登A..50—AN..100—D—D—AN..5護(hù)理質(zhì)量控制指標(biāo)名稱N1..4AN..200—D—AN..70—護(hù)理質(zhì)量分析會議主持人在公安管理部門正式登記注冊的姓氏和A..50—護(hù)理質(zhì)量分析會議參加人在公安管理部門正式登記注冊的姓氏和A..50—護(hù)理質(zhì)量分析會議記錄人在公安管理部門正式登記注冊的姓氏和A..50—AN..500—AN..5—A..50—NN1..3—AN..8—AN..10—AN..10—AN..5—D—風(fēng)險(xiǎn)評估總得分的實(shí)際值，計(jì)量單位為“分”NN..3—評估患者風(fēng)險(xiǎn)的護(hù)理人員在公安管理部門正式登記注冊的姓氏和A..50—A..50—AN..200——NN..3—A..50—D—AN..500—A..50—D—AN..100—A..50—AN..100—WS364.11衛(wèi)生信息數(shù)據(jù)元值域代碼D—AN..5A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—部分:護(hù)理操作記錄CV06.00.220護(hù)理患者發(fā)生輸液不良反應(yīng)后每分鐘脈搏的次數(shù)測量值,計(jì)量單位為次NN2..3—NN..2—患者發(fā)生輸液不良反應(yīng)后心臟搏動頻率的測量值,計(jì)量單位為次NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3—L—L—L—L—L—L—AN..50—NN..5,2—AN..6—NN..3—AN..50—AN..20—AN..50—AN..50—AN..50—AN..70—————AN..500—患者輸液不良反應(yīng)癥狀緩解當(dāng)日的公元紀(jì)年日期和時(shí)間的完整描述—L—L—輸液不良反應(yīng)事件上報(bào)當(dāng)日的公元紀(jì)年日期—輸液不良反應(yīng)事件上報(bào)人在公安管理部門正式登記注冊的姓氏和A..50—AN..500—AN..500—AN..50A..50—A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登記注冊的姓氏和名稱A..50—AN..5A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—部分:護(hù)理操作記錄CV06.00.220護(hù)患者發(fā)生藥品不良反應(yīng)后每分鐘脈搏的次數(shù)測量值,計(jì)量單位為次NN2..3—患者發(fā)生藥品不良反應(yīng)后每分鐘呼吸的次數(shù)NN..2—患者發(fā)生藥品不良反應(yīng)后心臟搏動頻率的測量值,計(jì)量單位為次NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3—L—AN..100—L—AN..100—L—L—L—藥物監(jiān)督管理部門對特定生產(chǎn)企業(yè)所生產(chǎn)的某一藥物的法律認(rèn)可AN..20—AN..50—懷疑藥物和并用藥物生產(chǎn)單位在機(jī)構(gòu)注冊的通用AN..70—AN..20—NN..5,2—AN..6——藥品不良反應(yīng)/事件發(fā)生當(dāng)日的公元紀(jì)年日—AN..500—藥品不良反應(yīng)/事件上報(bào)當(dāng)日的公元紀(jì)年日—藥品不良反應(yīng)/事件上報(bào)人在公安管理部門正式登記注冊的姓氏和A..50—AN..500—AN..500—AN..50—A..50—A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登記注冊的姓氏和名稱A..50—AN..5值域代碼第12部分：衛(wèi)生管理A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—患者發(fā)生跌倒/墜床后每分鐘脈搏的次數(shù)測量值,NN2..3—NN..2—患者發(fā)生跌倒/墜床后心臟搏動頻率的測量值NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3—DNN..3—AN..70—L—L—L—L—AN..200—AN..500—跌倒/墜床不良事件上報(bào)當(dāng)日的公元紀(jì)年日—A..50—AN..500—AN..500—AN..50A..50—A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登A..50—A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—患者發(fā)生非計(jì)劃拔管后每分鐘脈搏的次數(shù)測量值,計(jì)量單位為次NN2..3—NN..2—患者發(fā)生非計(jì)劃拔管后心臟搏動頻率的測量值NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3—L—L—L—N1..2——A..50—A..50—AN..500—既往非計(jì)劃拔管事件發(fā)L—L——A..50—AN..500—AN..500—AN..50—A..50—A..50—AN..200—A..50—AN..5值域代碼第12部分：衛(wèi)生管理A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—NN2..3—NN..2—NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3—L—L—L—對患者壓瘡程度進(jìn)行評估分級的結(jié)果在特定AN..200—NN..4,1—NN..4,1—NN..4,1——AN..500——壓瘡不良事件上報(bào)人在公安管理部門正式登A..50—AN..500—AN..500—AN..50—A..50—A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登A..50—AN..5中醫(yī)護(hù)理技術(shù)操作項(xiàng)目AN..70—值域代碼第12部分：衛(wèi)生管理A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—中醫(yī)護(hù)理技術(shù)操作不良事件發(fā)生后患者每分鐘脈搏的次數(shù)測量值,NN2..3—NN..2—中醫(yī)護(hù)理技術(shù)操作不良事件發(fā)生后患者心臟搏動頻率的測量值,計(jì)NN2..3—體溫(℃)中醫(yī)護(hù)理技術(shù)操作不良事件發(fā)生后患者體溫的測量值,計(jì)量單位NN4,1—中醫(yī)護(hù)理技術(shù)操作不良事件發(fā)生后患者舒張壓的測量值,計(jì)量單位NN2..3—中醫(yī)護(hù)理技術(shù)操作不良事件發(fā)生后患者收縮壓的測量值,計(jì)量單位NN2..3—L—L—L——AN..70—AN..500——A..50—AN..500—AN..500—AN..50—A..50—A..50—AN..200—護(hù)理部處理人簽署的在公安管理部門正式登A..50—AN..5A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—L—L—L—AN..50—AN..50—稱A..50—AN..100——AN..500—AN..500——A..50—AN..500—AN..500—AN..50—A..50A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登A..50—AN..5元值域代碼第12部分：衛(wèi)生管理A..50—NN1..3—AN..8—AN..10—AN..10——AN..5AN..50—護(hù)理不良事件發(fā)生后患者每分鐘脈搏的次數(shù)測量值,計(jì)量單位為次NN2..3—發(fā)生護(hù)理不良事件后患者每分鐘呼吸的次數(shù)，計(jì)量單NN..2—護(hù)理不良事件發(fā)生后患者心臟搏動頻率的測量值,計(jì)量單位為次NN2..3—體溫(℃)NN4,1—NN2..3—NN2..3——AN..70—AN..200—AN..500—A..50——AN..500—AN..500—AN..50A..50—A..50—AN..200—護(hù)理部主管領(lǐng)導(dǎo)簽署的在公安管理部門正式登A..50—AN..5醫(yī)院環(huán)境衛(wèi)生監(jiān)測—醫(yī)院環(huán)境衛(wèi)生監(jiān)測AN..100——AN..5A..50—NN1..3—AN..8—AN..20—AN..3D——AN..70—AN..200—L—L—職業(yè)暴露污染物類別代碼A..50—NN1..3—AN..8—AN..50—AN..500—L—A..50——醫(yī)療廢物重量數(shù)值的具體描述，計(jì)量單位為“kg”NN..3—NN..20—醫(yī)療廢物交出人員簽署的在公安管理部門正式登記注冊的姓氏和A..50—A..50———AN..20—A..50—AN..70—AN..20—NN..3—AN..20———AN..5A..50—學(xué)生考試成績的實(shí)際值，計(jì)量單位為“分”NN..3——AN..70—AN..70—AN..70—A..50—A..50—NN..9—AN..500—D—AN..70—AN..20—AN..20—A..50—AN..70—科研項(xiàng)目經(jīng)費(fèi)的實(shí)際數(shù)值，計(jì)量單位為“萬元”NN..9,2—L—AN..100—AN..70—D—AN..70—AN..20—A..50—D—科研項(xiàng)目組成員已取得的相關(guān)專業(yè)職稱在特定AN..70—NN..2—AN..200—AN..100—AN..20—D—組織科研成果鑒定單位名稱AN..70—D—AN..70—AN..70—AN..20—AN..70—護(hù)理專利項(xiàng)目發(fā)明人在公安管理部門正式登A..50—AN..5AN..20—D—AN..200—D—表17護(hù)理人員論文著作管理子集數(shù)據(jù)元專用屬性AN..70—AN..5護(hù)理新業(yè)務(wù)／技術(shù)負(fù)責(zé)人在公安管理部門正式登記注冊稱A..50—D——AN..200—AN..200—AN..500—AN..500—AN..500—AN..100———AN..500—A..50—AN..500—AN..500—AN..500—AN..50AN..100AN..500——AN..70—AN..100—AN..5AN..70—AN..20—D——AN..5AN..70—組織工休座談會的護(hù)士長在公安管理部門正式登記注稱A..50—A..50—A..50—A..50—NN..9—AN..500—AN..500—AN..200—AN..500—AN..100AN..5D—AN..70—AN..100—AN..500—A..50—A..50—A..50—AN..5AN..20——AN..200—5.3數(shù)據(jù)元值域代碼表值123459值1234VTE風(fēng)險(xiǎn)因素9值123456Ⅴ深部組織壞死呈潰瘍已延伸至骨骼、關(guān)節(jié)結(jié)構(gòu)7值123459值1234569值1無23451239值1吻合口以下胃管（食道、胃、胰十二指腸切除23123輕微傷害，生命體征無改變，需進(jìn)45重度傷害，生命體征明顯改變，需值67123459值123456789值12非潔凈手術(shù)部（室）、非潔凈骨髓移植病房、產(chǎn)房；導(dǎo)管室、新生兒室、器官移植病房、燒3兒科病房、母嬰同室、消毒供應(yīng)中心、血液透）；4普通門（急）診及其檢查（婦產(chǎn)科檢查室、人流室）、治療（注射、換藥等）室；輸血科、9值123459值1同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)實(shí)際開普通病房同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期重癥監(jiān)護(hù)病房同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)手術(shù)室同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)新生兒室同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期產(chǎn)房同期執(zhí)業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)實(shí)同期每天各班次患者數(shù)之和/統(tǒng)計(jì)周期（同期某級別護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)護(hù)（同期全院大專及以上學(xué)歷護(hù)士人數(shù)/（同期碩士研究生以上學(xué)歷或?qū)W位護(hù)士（同期具有高級專業(yè)技術(shù)職稱任職資格（同期具有本科以上學(xué)歷的護(hù)理管理人員人數(shù)/統(tǒng)計(jì)周期內(nèi)護(hù)理管理人員總?cè)藬?shù)）×100%（同期專科護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)護(hù)士總?cè)藬?shù)）×100%值中醫(yī)院校畢業(yè)護(hù)士或中醫(yī)護(hù)理專業(yè)畢業(yè)護(hù)(同期中醫(yī)院校畢業(yè)護(hù)士或中醫(yī)護(hù)理專業(yè)畢業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期內(nèi)護(hù)士總?cè)藬?shù)）×100%非中醫(yī)專業(yè)畢業(yè)護(hù)士系統(tǒng)接受中醫(yī)藥知識（同期系統(tǒng)接受中醫(yī)藥知識與技能培訓(xùn)的非中醫(yī)專業(yè)畢業(yè)護(hù)士人數(shù)/統(tǒng)計(jì)周期（同期護(hù)士離職人數(shù)/統(tǒng)計(jì)周期末護(hù)士(同期內(nèi)執(zhí)業(yè)護(hù)士實(shí)際上班小時(shí)數(shù)/統(tǒng)計(jì)2數(shù)/入院24小時(shí)內(nèi)的所有患者數(shù))×100%數(shù)/入院24小時(shí)內(nèi)的所有患者數(shù))×100%(同期住院患者身體約束日數(shù)/統(tǒng)計(jì)周期(同期住院患者進(jìn)行了疼痛評估的例數(shù)/3(同期住院患者中發(fā)生跌倒例次數(shù)/統(tǒng)計(jì)(同期住院患者中發(fā)生跌倒傷害某等級例次數(shù)/統(tǒng)計(jì)周期內(nèi)住院患者人日數(shù))×(同期住院患者中壓瘡新發(fā)病例數(shù)/統(tǒng)計(jì)(同期某導(dǎo)管非計(jì)劃性拔管例次數(shù)/統(tǒng)計(jì)(同期留置導(dǎo)尿管患者中尿路感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)患者留置導(dǎo)尿管總?cè)諗?shù))值(同期中心導(dǎo)管相關(guān)血流感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)中心導(dǎo)管插管總?cè)諗?shù))×(同期呼吸機(jī)相關(guān)性肺炎感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)有創(chuàng)機(jī)械通氣總?cè)諗?shù))×1-(全院急救設(shè)備應(yīng)急狀態(tài)不符合要1-(全院危險(xiǎn)品管理不符合要求數(shù)/全(同期中醫(yī)護(hù)理文書書寫達(dá)到合格的份數(shù)/統(tǒng)計(jì)周期內(nèi)中醫(yī)護(hù)理文書檢查(中醫(yī)護(hù)理查房達(dá)到優(yōu)良水平的次數(shù)/統(tǒng)計(jì)周期內(nèi)中醫(yī)護(hù)理查房的總次數(shù))(中醫(yī)護(hù)理培訓(xùn)達(dá)到合格的人數(shù)/統(tǒng)計(jì)周期內(nèi)進(jìn)行中醫(yī)護(hù)理培訓(xùn)的總?cè)藬?shù))×100%(中醫(yī)護(hù)理考核達(dá)到合格的人數(shù)/統(tǒng)計(jì)周期內(nèi)進(jìn)行中醫(yī)護(hù)理考核的總?cè)藬?shù))×100%(同期住院患者實(shí)施中醫(yī)護(hù)理技術(shù)后發(fā)生燙傷的例次數(shù)/統(tǒng)計(jì)周期內(nèi)實(shí)施中醫(yī)護(hù)理技術(shù)的住院患者總數(shù))×(同期住院患者進(jìn)行中藥注射液治療后發(fā)生輸液反應(yīng)的例次數(shù)/統(tǒng)計(jì)周期內(nèi)進(jìn)行中藥注射液治療的住院患者(同期出院患者隨訪的例數(shù)/統(tǒng)計(jì)周期（問卷各條目實(shí)際得分總和/問卷各條目總分）×100%(同期實(shí)施了中醫(yī)健康教育的病人數(shù)/統(tǒng)計(jì)周期內(nèi)所有住院患者人數(shù))×值(同期開展了中醫(yī)護(hù)理技術(shù)的病人例數(shù)/統(tǒng)計(jì)周期內(nèi)所有住院患者人數(shù))×(對疼痛患者實(shí)施中醫(yī)技術(shù)后疼痛緩解的例數(shù)/統(tǒng)計(jì)周期內(nèi)所有開展中醫(yī)(同期優(yōu)勢病種患者使用中醫(yī)護(hù)理方案的人數(shù)/統(tǒng)計(jì)周期內(nèi)優(yōu)勢病種患者(同期優(yōu)勢病種患者應(yīng)用中醫(yī)護(hù)理方案后進(jìn)行了效果評價(jià)的人數(shù)/統(tǒng)計(jì)周期內(nèi)實(shí)施優(yōu)勢病種中醫(yī)護(hù)理方案的值值1234值123459值123值值12349B病床號..................................................................DE01.00.026.00并發(fā)癥標(biāo)志..............................................................DE04.01.A09.00不良反應(yīng)發(fā)生日期時(shí)間....................................................DE09.00.H40.00不良事件類別代碼........................................................DE09.00.404.00不良事件發(fā)生經(jīng)過........................................................DE09.00.E56.00不良事件發(fā)生日期時(shí)間....................................................DE09.00.H40.00不良事件癥狀描述........................................................DE04.01.117.00標(biāo)準(zhǔn)總權(quán)重分.............................................................DE09.00.J06.00C穿刺針廠家名稱..........................................................DE08.50.A93.00參加人數(shù)................................................................DE06.00.241.00參加人姓名..............................................................DE02.01.039.00處理措施................................................................DE06.00.409.00測評得分.................................................................DE09.00.J01.00測評對象分類代碼........................................................DE09.00.F39.00測評內(nèi)容................................................................DE09.00.F40.00測評日期................................................................DE09.00.H99.00測評主體名稱............................................................DE09.00.F64.00從事專業(yè)年限............................................................DE08.30.C18.00持續(xù)質(zhì)量改進(jìn)項(xiàng)目名稱....................................................DE09.00.F25.00撤銷日期................................................................DE09.00.H59.00采樣日期時(shí)間.............................................................DE09.00.J30.00操作人姓名..............................................................DE02.01.039.00存在問題................................................................DE09.00.F67.00D導(dǎo)管類型代碼............................................................DE08.50.B03.00帶教對象類別代碼........................................................DE09.00.F95.00帶教老師姓名............................................................DE02.01.039.00登記日期時(shí)間.............................................................DE09.00.J31.00登記者姓名..............................................................DE02.01.039.00單位名稱................................................................DE08.10.007.00F封存標(biāo)志................................................................DE09.00.F49.00復(fù)查結(jié)果................................................................DE06.00.A24.00復(fù)查日期.................................................................DE09.00.J12.00復(fù)查者姓名..............................................................DE02.01.039.00非計(jì)劃拔管日期時(shí)間......................................................DE09.00.J29.00反饋記錄................................................................DE09.00.F68.00發(fā)明人姓名..............................................................DE02.01.039.00復(fù)評得分................................................................DE09.00.J18.00復(fù)評日期時(shí)間............................................................DE09.00.J17.00復(fù)評人姓名..............................................................DE02.01.039.00風(fēng)險(xiǎn)程度代碼...........................................................DE05.10.A03.00風(fēng)險(xiǎn)評估項(xiàng)目代碼.......................................................DE05.10.A02.00發(fā)現(xiàn)人姓名..............................................................DE02.01.039.00負(fù)責(zé)人姓名..............................................................DE02.01.039.00G改進(jìn)措施...............................................................DE06.00.A19.00工作計(jì)劃................................................................DE09.00.F57.00工作年限...............................................................DE08.30.A88.00工作總結(jié)................................................................DE09.00.F58.00H合格分..................................................................DE09.00.F23.00獲獎日期................................................................DE09.00.J42.00護(hù)理部處理人簽名........................................................DE02.01.039.00護(hù)理部處理意見..........................................................DE06.00.018.00護(hù)理不良事件等級代碼...................................................DE09.00.E55.00護(hù)理部主管領(lǐng)導(dǎo)簽名......................................................DE02.01.039.00護(hù)理等級代碼............................................................DE06.00.211.00護(hù)理大事記編號..........................................................DE09.00.F59.00護(hù)理大事記內(nèi)容..........................................................DE09.00.F60.00護(hù)理服務(wù)滿意度..........................................................DE09.00.F41.00護(hù)理考試類別代碼........................................................DE09.00.F27.00護(hù)理人員工號...........................................................DE08.30.A85.00護(hù)理人員姓名............................................................DE02.01.039.00護(hù)理質(zhì)量管理計(jì)劃........................................................DE09.00.F15.00護(hù)理質(zhì)量管理目標(biāo)........................................................DE09.00.F14.00護(hù)理質(zhì)量檢查級別........................................................DE09.00.J10.00護(hù)理質(zhì)量控制指標(biāo)結(jié)果....................................................DE09.00.F19.00護(hù)理質(zhì)量控制指標(biāo)名稱分類代碼............................................DE09.00.F18.00護(hù)理質(zhì)量評價(jià)標(biāo)準(zhǔn)名稱代碼................................................DE09.00.F20.00評價(jià)內(nèi)容................................................................DE09.00.J07.00護(hù)士長簽名..............................................................DE02.01.039.00護(hù)士長姓名..............................................................DE02.01.039.00呼吸次數(shù)(次/min)........................................................DE04.10.081.00呼吸困難標(biāo)志............................................................DE04.01.546.01會議地點(diǎn)...............................................................DE09.00.B9會議內(nèi)容................................................................DE09.00.F06.00會議日期.................................................................DE09.00.J13.00會議日期時(shí)間............................................................DE09.00.B90.00會議主題................................................................DE09.00.F05.00寒顫標(biāo)志................................................................DE04.01.C30.00患者參加人數(shù)............................................................DE06.00.241.00患者年齡（歲）.................................................患者年齡（月）.................................................患者性別代碼............................................................DE02.01.040.00患者姓名................................................................DE02.01.039.00患者意見................................................................DE09.00.F43.00J疾病診斷代碼............................................................DE05.01.024.00疾病診斷名稱............................................................DE05.01.025.00獎懲部門名稱............................................................DE08.10.401.00檢查得分.................................................................DE09.00.J11.00獎懲對象................................................................DE09.00.F12.00獎懲類別代碼............................................................DE09.00.F11.00獎懲名稱.................................................................DE09.00.J49.00檢查日期................................................................DE04.50.140.00獎懲日期時(shí)間.............................................................DE09.00.J48.00檢查者姓名..............................................................DE02.01.039.00交出者姓名..............................................................DE02.01.039.00計(jì)劃制定人姓名..........................................................DE02.01.039.00交接日期時(shí)間............................................................DE09.00.107.00健康教育標(biāo)志............................................................DE06.00.A25.00獎勵名稱................................................................DE09.00.F13.00記錄日期時(shí)間.............................................................DE09.00.J50.00記錄人姓名..............................................................DE02.01.039.00靜脈穿刺日期時(shí)間........................................................DE06.00.183.00結(jié)束日期時(shí)間............................................................DE09.00.K64.00接收者姓名..............................................................DE02.01.039.00結(jié)題日期.................................................................DE09.00.J39.00既往非計(jì)劃拔管事件發(fā)生標(biāo)志..............................................DE05.10.A17.00既往藥物不良反應(yīng)標(biāo)志....................................................DE06.00.129.00既往藥物不良反應(yīng)描述....................................................DE06.00.130.00教學(xué)部門名稱............................................................DE08.10.401.00教學(xué)地點(diǎn).................................................................DE09.00.J36.00臨床教學(xué)內(nèi)容分類代碼....................................................DE09.00.F35.00教學(xué)日期時(shí)間............................................................DE09.00.G27.00教學(xué)效果評價(jià).............................................................DE09.00.J37.00教學(xué)項(xiàng)目名稱.............................................................DE09.00.J35.00截止日期...............................................................DE09.00.H72.00家族藥物不良反應(yīng)標(biāo)志....................................................DE06.00.129.00家族藥物不良反應(yīng)描述....................................................DE06.00.130.00K科護(hù)士長簽名............................................................DE02.01.039.00考試成績................................................................DE09.00.F29.00科室代碼................................................................DE08.10.025.00開始日期時(shí)間...........................................................DE09.00.K75.00科研成果鑒定級別代碼...................................................DE09.00.E86.00科研成果鑒定日期.......................................................DE09.00.G48.00科研成果鑒定形式代碼....................................................DE09.00.E87.00科研成果鑒定證書編號....................................................DE09.00.J41.00科研成果名稱...........................................................DE09.00.G50.00科研合作單位名稱........................................................DE08.10.013.00科研項(xiàng)目編號............................................................DE09.00.F72.00科研項(xiàng)目負(fù)責(zé)人單位名稱..................................................DE08.10.013.00科研項(xiàng)目負(fù)責(zé)人姓名......................................................DE02.01.039.00科研項(xiàng)目級別代碼.......................................................DE09.00.E79.00科研項(xiàng)目經(jīng)費(fèi)...........................................................DE09.00.E80.00科研項(xiàng)目合作標(biāo)志.......................................................DE09.00.E81.00科研項(xiàng)目合作形式.......................................................DE09.00.E82.00科研項(xiàng)目名稱...........................................................DE09.00.E78.00科研項(xiàng)目下達(dá)文號.......................................................DE09.00.E77.00科研項(xiàng)目組承擔(dān)項(xiàng)目任務(wù)..................................................DE09.00.J40.00科研項(xiàng)目組成員出生日期..................................................DE02.01.005.01科研項(xiàng)目組成員工作單位..................................................DE08.10.007.00科研項(xiàng)目組成員性別代碼..................................................DE02.01.040.00科研項(xiàng)目組成員姓名......................................................DE02.01.039.00科研項(xiàng)目組成員職稱代碼..................................................DE02.01.049.00科研項(xiàng)目組研究成員位次.................................................DE09.00.E83.00開展日期時(shí)間............................................................DE09.00.J45.00L冷藏標(biāo)志...............................................................DE08.50立項(xiàng)日期................................................................DE09.00.J38.00M脈率(次/min)............................................................DE04.10.118.00N年齡（歲）..............................................................DE02.01.026.00P評分標(biāo)準(zhǔn)................................................................DE09.00.F66.00皮膚出疹標(biāo)志............................................................DE04.01.A07.00皮膚破損標(biāo)志............................................................DE05.10.A15.00評估得分.................................................................DE09.00.J16.00評估日期................................................................DE09.00.J15.00陪護(hù)標(biāo)志................................................................DE09.00.F50.00評價(jià)方法................................................................DE09.00.F65.00評價(jià)內(nèi)容.................................................................DE09.00.J07.00評價(jià)項(xiàng)目權(quán)重分值.........................................................DE09.00.J08.00批準(zhǔn)文號................................................................DE09.00.E77.00Q起始日期................................................................DE09.00.H71.00R入院日期時(shí)間............................................................DE06.00.092.00S上報(bào)日期時(shí)間.............................................................DE09.00.J14.00上報(bào)人姓名..............................................................DE02.01.039.00審核通過日期.............................................................DE09.00.J44.00授獎單位名稱............................................................DE08.10.007.00事件發(fā)生地點(diǎn).............................................................DE09.00.J26.00事件發(fā)生經(jīng)過.............................................................DE09.00.J27.00事件發(fā)生日期時(shí)間.........................................................DE09.00.J25.00傷情程度代碼............................................................DE05.10.A10.00授權(quán)公告日...............................................................DE09.00.J43.00收縮壓（mm/Hg）.......................................................DE04.10.174.00失效日期................................................................DE08.50.F59.00事業(yè)單位編制標(biāo)志........................................................DE08.30.A86.00輸液器廠家名稱..........................................................DE08.50.A93.00使用約束保護(hù)措施標(biāo)志....................................................DE06.00.A20.00使用約束措施標(biāo)志........................................................DE06.00.A20.00適應(yīng)證...................................................................DE09.00.J46.00神志類別代碼............................................................DE04.01.A10.00舒張壓（mm/Hg）.......................................................DE04.10.176.00T體溫(℃)..............................................................DE04.10.186.00X性別代碼................................................................DE02.01.040.00效果評價(jià)................................................................DE06.00.A22.00心率(次/min)............................................................DE04.10.206.00學(xué)歷代碼................................................................DE02.01.041.00學(xué)生編號................................................................DE09.00.F55.00學(xué)生姓名................................................................DE02.01.039.00新業(yè)務(wù)/技術(shù)項(xiàng)目名稱....................................................DE09.00.E91.00小組成員姓名............................................................DE02.01.039.00小組名稱................................................................DE09.00.J03.00行走能力代碼...........................................................DE05.10.A19.00小組職責(zé)分工日期.......................................................DE09.00.J02.00Y壓瘡部位...............................................................DE05.10.A05.00壓瘡分期代碼...........................................................DE05.10.A09.00壓瘡來源代碼...........................................................DE05.10.A04.00壓瘡面積-長（cm）......................................................DE05.10.A06.00壓瘡面積-寬（cm）......................................................DE05.10.A07.00壓瘡面積-深（cm）......................................................DE05.10.A08.00預(yù)防措施................................................................DE06.00.295.00預(yù)防性治療標(biāo)志.........................................................DE06.00.A18.00預(yù)期目標(biāo)...............................................................DE06.00.A21.00醫(yī)療廢物類別代碼........................................................DE09.00.F37.00醫(yī)療廢物數(shù)量............................................................DE06.00.241.00醫(yī)療廢物重量............................................................DE09.00.F38.00儀器設(shè)備廠家名稱.......................................................DE08.50.A93.00儀器設(shè)備類別代碼.......................................................DE08.50.A89.00儀器設(shè)備商品名稱.......................................................DE08.50.A90.00意識狀態(tài)代碼...........................................................DE05.10.A18.00藥物廠家名稱...........................................................DE08.50.A93.00藥物名稱................................................................DE08.50.022.00藥物批號...............................................................DE08.50.B藥物配置地點(diǎn)............................................................DE09.00.J21.00藥物配置日期時(shí)間.......................................................DE06.00.E01.00藥物批準(zhǔn)文號............................................................DE09.00.E77.00藥物生產(chǎn)批號...........................................................DE08.50.B藥物輸入日期時(shí)間........................................................DE09.00.J23.00藥物使用次劑量..........................................................DE08.50.023.00藥物使用劑量單位........................................................DE08.50.024.00藥物使用天數(shù)...........................................................DE08.50.B原因分析...............................................................DE06.00.A23.00醫(yī)院環(huán)境類別代碼........................................................DE09.00.F08.00醫(yī)院環(huán)境衛(wèi)生監(jiān)測結(jié)果....................................................DE09.00.F10.00醫(yī)院環(huán)境衛(wèi)生監(jiān)測項(xiàng)目代碼................................................DE09.00.F09.00用藥開始日期時(shí)間........................................................DE09.00.J24.00應(yīng)用效果................................................................DE09.00.J47.00Z組長標(biāo)志.................................................................DE09.00.J05.00職稱代碼................................................................DE02.01.049.00主持人姓名..............................................................DE02.01.039.00制度更新日期............................................................DE09.00.H97.00制度名稱................................................................DE09.00.F31.00制度內(nèi)容................................................................DE09.00.F32.00制定日期................................................................DE09.00.H73.00制度生效日期............................................................DE09.00.H96.00制度失效日期...........................................