ICS11.020 CCSC07 4401 广州市地方标准 DB4401/T304.8—2024 卫生健康数据采集规范第8部分： 医疗服务与运营管理 Datacollectionspecificationforhealthdata —Part8:Medicalservicesandoperationsmanagement 2024-12-20发布 2025-01-20实施 广州市市场监督管理局  发布 DB4401/T304.8—2024 I目次 前言.................................................................................III 1范围................................................................................1 2规范性引用文件......................................................................1 3术语和定义..........................................................................2 4数据元属性描述规则..................................................................2 5医疗服务与运营管理数据目录..........................................................2 附录A（规范性）数据集...............................................................12 A.1医疗服务基础信息...............................................................12 A.2临床诊疗记录...................................................................30 A.3电子病历.......................................................................67 A.4病案首页......................................................................246 A.5检验检查......................................................................307 A.6用血管理......................................................................326 A.7家庭病床......................................................................354 A.8手术麻醉......................................................................358 A.9体检信息......................................................................374 A.10转诊（院）记录...............................................................387 A.11法定医学证明及报告...........................................................391 A.12院感管理.....................................................................399 A.13血透质控.....................................................................403 A.14腹透管理.....................................................................423 A.15院前急救.....................................................................446 A.16重症医学.....................................................................481 A.17中医药.......................................................................490 A.18专科疾病-脑科................................................................584 A.19专科疾病-呼吸科..............................................................612 A.20专科疾病-胸科................................................................634 A.21专科疾病-肿瘤科..............................................................639 A.22专科疾病-口腔科..............................................................661 A.23专科疾病-皮肤科..............................................................664 A.24医院运营.....................................................................671 A.25医保药品溯源码...............................................................754 附录B（规范性）代码表..............................................................760 B.1卡类型代码表..................................................................760 B.2胸廓外形类型代码表............................................................760 B.3呼吸节律类型代码表............................................................760 B.4胸廓扩张度代码表..............................................................761 DB4401/T304.8—2024 IIB.5语音震颤类型代码表............................................................761 B.6胸膜摩擦感类型代码表..........................................................761 B.7叩诊音类型代码表..............................................................762 B.8呼吸音类型代码表..............................................................762 B.9啰音类型代码表................................................................762 B.10语音共振类型代码表...........................................................763 B.11哮鸣音时相类型代码表.........................................................763 B.12患者初复诊类型代码表.........................................................763 B.13通风情况代码表...............................................................764 B.14结核菌群检测结果代码表.......................................................764 B.15痰菌情况代码表........................................