档案管理

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分类专栏： HL7 协议分析文章标签：档案管理

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9. Medical Records /Information Management
(Document Management)

9．病历档案/信息管理（档案管理）

Chapter Chair/Editor:

本章负责人/编辑：

Wayne Tracy, MS
Health Patterns, LLC

Chapter Chair/Editor:

本章负责人/编辑：

Harry Rhodes
American Health Information Management Association

美国健康信息管理协会

Note: No substantive changes were made to this chapter for Version 2.4.

注意：本章对于2.4版没有做很多的改变。

1. Chapter 9 contents

9.1 第 9章目录

9.1 Chapter 9 contents.............................................................................................................................................. 1

9.1 第 9章目录…………………………………………………………………………………………………. 1

9.2 PURPOSES......................................................................................................................................................................... 4

9.2 目的…………………………………………………………………..…………………………….………..4

9.2.1 Definition of terms and concepts.................................................................................................. 5

9.2.1 术语和概念的定义......................................................................................................................................... 5

9.2.1.1 Addendum:....................................................................................................................................................... 5

9.2.1.1 附录:....................................................................................................................................................................... 5

9.2.1.2 Archived:......................................................................................................................................................... 5

9.2.1.2 完成存档:.............................................................................................................................................................. 5

9.2.1.3 Canceled:........................................................................................................................................................ 5

9.2.1.3 完成删除:.............................................................................................................................................................. 5

9.2.1.4 Composite document:............................................................................................................................ 5

9.2.1.4 复合档案:.............................................................................................................................................................. 5

9.2.1.5 Document completion table:........................................................................................................ 6

9.2.1.5 档案完成表:......................................................................................................................................................... 6

9.2.1.6 Authenticated:.......................................................................................................................................... 6

9.2.1.6 完成鉴别:.............................................................................................................................................................. 6

9.2.1.6.1 Dictated:................................................................................................................................................. 6

9.2.1.6.1 完成口述:..................................................................................................................................................... 6

9.2.1.6.2 Documented:........................................................................................................................................ 6

9.2.1.6.2 完成编档:..................................................................................................................................................... 6

9.2.1.6.3 In progress/assigned:.................................................................................................................... 6

9.2.1.6.3 操作中/指定:............................................................................................................................................... 6

9.2.1.6.4 Incomplete:.......................................................................................................................................... 6

9.2.1.6.4 未完成:......................................................................................................................................................... 6

9.2.1.7 Legally authenticated:.................................................................................................................... 7

9.2.1.7 完成合法地鉴别:................................................................................................................................................ 7

9.2.1.7.1 Pre-authenticated:....................................................................................................................... 7

9.2.1.7.1 鉴别前:......................................................................................................................................................... 7

9.2.1.8 Edited document:..................................................................................................................................... 7

9.2.1.8 编辑档案:.............................................................................................................................................................. 7

9.2.1.9 New or original document:............................................................................................................. 7

9.2.1.9 新档案或原档案:................................................................................................................................................ 7

9.2.1.10 Obsolete:.................................................................................................................................................... 7

9.2.1.10 废弃:................................................................................................................................................................... 7

9.2.1.11 Purged:.......................................................................................................................................................... 7

9.2.1.11 清除:................................................................................................................................................................... 7

9.2.1.12 Replacement document:................................................................................................................ 8

9.2.1.12 替换档案:......................................................................................................................................................... 8

9.2.1.13 Restricted:................................................................................................................................................ 8

9.2.1.13 限制:................................................................................................................................................................... 8

9.2.1.14 Revised document:............................................................................................................................... 8

9.2.1.14 修订档案:......................................................................................................................................................... 8

9.2.1.15 Transcription:........................................................................................................................................ 8

9.2.1.15 转录:................................................................................................................................................................... 8

9.3 DOCUMENT MANAGEMENT SECTION................................................................................................................ 8

9.3 档案管理节........................................................................................................................................................................ 8

9.4 ASSUMPTIONS................................................................................................................................................................ 9

9.4 假设...................................................................................................................................................................................... 9

9.5 TRIGGER EVENTS AND MESSAGE DEFINITIONS........................................................................................... 9

9.5 触发事件和信息定义..................................................................................................................................................... 9

9.5.1 MDM/ACK - original document notification (event T01).............................................. 10

9.5.1 MDM/ACK - 原档案通告(事件码T01)......................................................................................................... 10

9.5.2 MDM/ACK - original document notification and content (event T02)............. 11

9.5.2 MDM/ACK - 原档案通告和内容（事件码T02）.................................................................................... 11

9.5.3 MDM/ACK - document status change notification (event T03)............................... 12

9.5.3 MDM/ACK - 档案状态改变通告（事件码T03）.................................................................................... 12

9.5.4 MDM/ACK - document status change notification and content (event T04) 13

9.5.4 MDM/ACK - 档案状态改变通告和内容(事件码T04)............................................................................. 13

9.5.5 MDM/ACK - document addendum notification (event T05)........................................... 14

9.5.5 MDM/ACK - 档案附录通告（事件码T05）............................................................................................. 14

9.5.6 MDM/ACK - document addendum notification and content (event T06).......... 14

9.5.6 MDM/ACK - 档案附录通告和内容(事件码T06)...................................................................................... 14

9.5.7 MDM/ACK - Document edit notification (event T07)..................................................... 15

9.5.7 MDM/ACK - 档案编辑通告(事件码T07).................................................................................................... 15

9.5.8 MDM/ACK - document edit notification and content (event T08)......................... 16

9.5.8 MDM/ACK - 档案编辑通告和内容(事件码T08)...................................................................................... 16

9.5.9 MDM/ACK - document replacement notification (event T09).................................. 17

9.5.9 MDM/ACK - 档案替换通告（事件码T09）............................................................................................. 17

9.5.10 MDM/ACK - document replacement notification and content (event T10) 17

9.5.10 MDM/ACK - 档案替换通告和内容（事件码T10）............................................................................... 17

9.5.11 MDM/ACK - document cancel notification (event T11).................................................. 18

9.5.11 MDM/ACK - 档案删除通告（事件码T11）............................................................................................. 18

9.6 MESSAGE SEGMENTS............................................................................................................................................... 19

9.6 信息段............................................................................................................................................................................... 19

9.6.1 TXA - transcription document header segment............................................................... 19

9.6.1 TXA - 转录档案标题段..................................................................................................................................... 19

9.6.1.0 TXA field definitions....................................................................................................................... 21

9.6.1.0 TXA 字段定义............................................................................................................................................... 21

9.6.1.1 TXA-1 Set ID - TXA (SI) 00914........................................................................................................... 21

9.6.1.1 TXA-1 设置 ID - TXA (SI) 00914......................................................................................................... 21

9.6.1.2 TXA-2 Document type (IS) 00915....................................................................................... 21

9.6.1.2 TXA-2 档案类型 (IS) 00915........................................................................................................... 21

9.6.1.3 TXA-3 Document content presentation (ID) 00916............................................ 22

9.6.1.3 TXA-3 档案内容陈述 (ID) 00916..................................................................................................... 22

9.6.1.4 TXA-4 Activity date/time (TS) 00917................................................................................... 23

9.6.1.4 TXA-4 活动日期/时间(TS) 00917...................................................................................................... 23

9.6.1.5 TXA-5 Primary activity provider code/name (XCN) 00918............................ 23

9.6.1.5 TXA-5 主要活动提供者代码/姓名 (XCN) 00918...................................................................... 23

9.6.1.6 TXA-6 Origination date/time (TS) 00919...................................................................... 24

9.6.1.6 TXA-6 创建日期/时间 (TS) 00919................................................................................................. 24

9.6.1.7 TXA-7 Transcription date/time (TS) 00920................................................................. 24

9.6.1.7 TXA-7 转录日期/时间 (TS) 00920................................................................................................. 24

9.6.1.8 TXA-8 Edit date/time (TS) 00921.......................................................................................... 24

9.6.1.8 TXA-8 编辑日期/时间 (TS) 00921................................................................................................. 24

9.6.1.9 TXA-9 Originator code/name (XCN) 00922.................................................................. 24

9.6.1.9 TXA-9 创建者代码/姓名 (XCN) 00922........................................................................................ 24

9.6.1.10 TXA-10 Assigned document authenticator (XCN) 00923................................ 25

9.6.1.10 TXA-10 指定的档案鉴别人(XCN) 00923................................................................................... 25

9.6.1.11 TXA-11 Transcriptionist code/name (XCN) 00924............................................. 25

9.6.1.11 TXA-11 转录者代码/姓名 (XCN) 00924.................................................................................. 25

9.6.1.12 TXA-12 Unique document number (EI) 00925......................................................... 26

9.6.1.12 TXA-12 唯一的档案号码 (EI) 00925........................................................................................ 26

9.6.1.13 TXA-13 Parent document number (EI) 00926........................................................ 26

9.6.1.13 TXA-13 原始档案号码 (EI) 00926............................................................................................ 26

9.6.1.14 TXA-14 Placer order number (EI) 00216.................................................................. 26

9.6.1.14 TXA-14 放置器指令号码 (EI) 00216........................................................................................ 26

9.6.1.15 TXA-15 Filler order number (EI) 00217.................................................................... 27

9.6.1.15 TXA-15 填充符指令号码 (EI) 00217........................................................................................ 27

9.6.1.16 TXA-16 Unique document file name (ST) 00927................................................... 28

9.6.1.16 TXA-16 唯一的档案文件名称 (ST) 00927.............................................................................. 28

9.6.1.17 TXA-17 Document completion status (ID) 00928.............................................. 28

9.6.1.17 TXA-17 档案完成状态 (ID) 00928............................................................................................ 28

9.6.1.18 TXA-18 Document confidentiality status (ID) 00929................................... 32

9.6.1.18 TXA-18 档案机密状态 (ID) 00929............................................................................................ 32

9.6.1.19 TXA-19 Document availability status (ID) 00930................................................ 33

9.6.1.19 TXA-19 档案有效状态(ID) 00930................................................................................................. 33

9.6.1.20 TXA-20 Document storage status (ID) 00932........................................................... 34

9.6.1.20 TXA-20 档案存储状态(ID) 00932................................................................................................. 34

9.6.1.21 TXA-21 Document change reason (ST) 00933........................................................ 35

9.6.1.21 TXA-21 档案改变理由 (ST) 00933............................................................................................ 35

9.6.1.22 TXA-22 Authentication person, time stamp (set) (PPN) 00934................. 35

9.6.1.22 TXA-22 鉴别人，时间标记（设置） (PPN) 00934............................................................. 35

9.6.1.22.1 Authentication person (component) (XCN)........................................................... 36

9.6.1.22.1 鉴别人（组成） (XCN)....................................................................................................................... 36

9.6.1.22.2 Authentication time stamp (component) (TS)..................................................... 36

9.6.1.22.2 鉴别时间标记（组成） (TS)........................................................................................................... 36

9.6.1.23 TXA-23 Distributed copies (XCN) 00935..................................................................... 36

9.6.1.23 TXA-23 复印件的分发 (XCN) 00935........................................................................................ 36

9.6.2 OBX - observation segment usage................................................................................................. 37

9.6.2 OBX - 观察报告段用法..................................................................................................................................... 37

9.7 EXAMPLE MESSAGE................................................................................................................................................. 38

9.7 实例信息.......................................................................................................................................................................... 38

9.8 QUERY............................................................................................................................................................................. 39

9.8 询问程序.......................................................................................................................................................................... 39

9.8.1 QRY/DOC - document query (event T12)....................................................................................... 39

9.8.1 QRY/DOC - 档案询问程序(事件码 T12).................................................................................................... 39

9.8.1.1 Query usage notes................................................................................................................................. 40

9.8.1.1 询问程序用法注意事项................................................................................................................................. 40

9.9 OUTSTANDING ISSUES............................................................................................................................................. 40

9.9 重要的问题…………………………………………………………………………………………………40

1. PURPOSES

9.2 目的

This chapter currently supports document management. In the future, it is intended also to support the data exchange needs of applications supporting other medical record functions, including chart location and tracking, deficiency analysis, consents, and release of information. The main purpose of the medical record is to produce an accurate, legal, and legible document that serves as a comprehensive account of healthcare services provided to a patient.

目前，本章支持档案的管理。今后，也将对支持其他病历档案功能的应用程序所需的数据交换，包括图表的定位和跟踪，缺乏分析，和信息的发布等提供支持。病历档案的主要目的是制造出正确的、合法的和易读的档案作为提供给病人的一份全面的医疗服务的说明。

This chapter defines the transactions at the seventh level, i.e., the abstract messages. Various schemes may be used to generate the actual characters that comprise the messages according to the communications environment. The HL7 Encoding Rules will be used where there is not a complete Presentation Layer. This is described in Chapter 1, “Relationship to Other Protocols.” The examples in this chapter were constructed using the HL7 Encoding Rules.

本章定义在第七层（应用层）的处理事项，即抽象信息。使用各种各样的方案来生成由根据通信环境而定的信息组成的实际的字符。HL7编码规则将被用在不是完全图像层的地方。这在第1章“与其他协议的关系”中有描述。本章所提供的范例都建立在使用HL7编码规则的基础之上。

1. 1. Definition of terms and concepts

9.2.1 术语和概念的定义

This part provides definition of terms used throughout this chapter. The intent of this part is to provide clarification on use and interpretation.

这部分提供在本章中使用的术语的定义。这部分的意图在于提供在使用和译码上的说明。

1. 1. 2. Addendum:

9.2.1.1 附录：

An appendage to an existing document that contains supplemental information. The parent document remains in place and its content is unaltered.

附录指包含有追加信息的已存在的档案。原始档案保留在适当的位置上，它的内容没有被改变。

1. 1. 1. Archived:

9.2.1.2 完成存档：

A storage status in which a document has been stored off-line for long-term access.

存储状态指为了长期读取某份档案而将其离线保存。

1. 1. 1. Canceled:

9.2.1.3 完成删除：

An availability status in which a document has been “removed” from a patient’s record with no replacement. This is done when a document has been erroneously created or assigned to the incorrect patient.

在一个档案内的有效状态已经被从病人的记录中删除了，并没有替换。这在当一个档案被错误地建立或者指定给错误的病人的时候执行。

1. 1. 1. Composite document:

9.2.1.4 复合档案：

A document which consists of an original document and one or more addenda.

一个档案包含有原档案和一个或者多个附录。

1. 1. 1. Document completion table:

9.2.1.5 档案完成表：

The following terms are used to describe the workflow progression of a document:

以下的术语是用来描述一个档案的制作流程的。

1. 1. 1. Authenticated:

9.2.1.6 完成鉴别：

A completion status in which a document or entry has been signed manually or electronically by one or more individuals who attest to its accuracy. No explicit determination is made that the assigned individual has performed the authentication. While the standard allows multiple instances of authentication, it would be typical to have a single instance of authentication, usually by the assigned individual.

完成状态指一个档案或者输入项已经被一个或多个证明其正确性的个人手写或电子地签署了。对于已经执行鉴别的指定的个人没有做出明确的决定。当标准允许鉴别的多个形式的同时，它将典型地拥有鉴别的一个单一形式，通常通过指定的个人得到。

1. 1. 1. 1. Dictated:

9.2.1.6.1 完成口述：

A completion status in which information has been orally recorded but not yet transcribed.

完成状态指信息已经完成了口述记录，但还没有被转录。

1. 1. 1. 1. Documented:

9.2.1.6.1 完成编档：

A completion status in which document content, other than dictation, has been received but has not been translated into the final electronic format. Examples include paper documents, whether hand-written or typewritten, and intermediate electronic forms, such as voice to text.

完成状态指档案内容除了口述部分，已经被接收，但是没有被转化成最终的电子格式。例子包括手写的或打印的文档及中介的电子窗体等，例如，从声音转到文本。

1. 1. 1. 1. In progress/assigned:

9.2.1.6.3 操作中/指定：

A workflow status in which the recipient has assigned the material to personnel to perform the task of transcription. The document remains in this state until the document is transcribed.

流程状态指接收器已经将材料指派给人员以执行转录任务。该档案保留在此状态中直到档案被完全转录。

1. 1. 1. 1. Incomplete:

9.2.1.6.4 未完成：

A completion status in which information is known to be missing from a transcribed document.

完全状态指信息在一个已转录的档案中遗失。

1. 1. 1. Legally authenticated:

9.2.1.7 完成合法地鉴别：

A completion status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry. This is the most mature state in the workflow progression.

完全状态指一个档案或输入项已经被对该档案或输入项负有合法责任的个人手动或电子签署了。这是在一个操作流程中最成熟的状态。

1. 1. 1. 1. Pre-authenticated:

9.2.1.7.1 鉴别前：

A completion status in which a document is transcribed but not authenticated.

完全状态指一个档案被转录但还没有被鉴别。

1. 1. 1. Edited document:

9.2.1.8 编辑档案：

A document that alters an existing document which had not been made available for patient care (see also Section 9.1.1.10, “Replacement document”).

改变一个已经存在的，但对病人医疗服务无效的档案。（参看9.1.1.10节“替换档案”）

1. 1. 1. New or original document:

9.2.1.9 新档案或原档案：

The first version of a document. The original may or may not be final or authenticated. An original document should have a set of associated statuses to define its current condition.

一个档案的第一版本。此原版本有可能成为最终版本或被鉴别。一个原档案应有一组相关联的状态来定义它的当前情形。

1. 1. 1. Obsolete:

9.2.1.10 废弃：

An availability status in which a document has been replaced by a document which contains revised content.

有效状态指一个档案已经被包含修订内容的档案所替代。

1. 1. 1. Purged:

9.2.1.11 清除：

A storage status in which a document is no longer available in this system.

存储状态指一个档案不再在这个系统中有效。

1. 1. 1. Replacement document:

9.2.1.12 替换档案：

A document that replaces an existing document. The original document becomes obsolete, but is still retained in the system for historical reference.

一个档案替换一个已经存在的档案。原档案被废弃，但仍然保留在系统中作为历史记录以备参考。

1. 1. 1. Restricted:

9.2.1.13 限制：

A confidentiality status in which access to a document has institutionally assigned limitations.

机密状态指已经制度化地指定了进入某个档案的限制。

1. 1. 1. Revised document:

9.2.1.14 修订档案：

This is not a supported trigger event. See Sections 9.1.1.6, “Edited document”, and 9.1.1.10 “Replacement document”.

这不是一个被支持的触发事件。参看9.1.1.6节“编辑档案”和9.1.1.10节“替换档案”。

1. 1. 1. Transcription:

9.2.1.15 转录：

A process of transforming dictated or otherwise documented information into an electronic format.

转换口述或其他形式的编档信息到电子格式的过程。

1. DOCUMENT MANAGEMENT SECTION

9.3 档案管理节

This section defines the Medical Document Management (MDM) transaction set. It supports transmission of new or updated documents or information about their status(es). The trigger events and messages may be divided into two broad categories, one which describes the statuses of documents, and one which both describes the statuses and contains the document content itself.

本节定义病历档案管理(MDM)处理事项集。它支持新的或更新的档案或信息的状态方面的传送。触发事件和信息可以被分成两大种类，一类描述档案的状态，另一类在描述档案状态的同时还包含档案的内容。

The document management section is concerned primarily with the management of those documents and entries which are created as a result of a transcription process. These documents are created in two distinct contexts, one of which is related to an order and describes the procedures or activities associated with that order, and another which occurs independent of the order process. The scope of this section also includes any document that contains data derived from orders or results but which must be treated as aggregate display data due to system limitations. This is a transition strategy to support integration of data across the continuum of care.

档案管理节主要与作为一个转录过程的结果而创建的那些档案和输入项的管理有关。这些档案被创建成两个截然不同的部分，一个部分与指令有关，并描述与该指令相联系的程序或活动；另一个部分的发生独立于该指令的操作。本节还包括包含源于指令或结果的数据的档案，但是由于系统的限制，这些指令或结果必须作为集合显示数据。这是一个过渡策略用来支持贯穿医疗服务过程中的数据的综合。

The content of a document can be represented with one or more observation segments (OBX). Where headings or separations naturally exist within the text, it is preferred that each of these blocks be represented as a separate OBX record. Where systems are able to decompose the text into separate medical concepts, the most atomic level of granularity of content should be represented, ideally with each medical concept being represented in its own OBX segment. Many of these concepts can be represented as coded entities.

一个档案的内容能够用一个或更多的观察报告段(OBX)来表示。在自然存在于该文本中的标题或单独部分的地方，首选每个数据块作为一个单独的OBX记录来表示。在系统能够将该文本分解成独立的医疗概念的地方，内容的最小间隔单位层应该在概念上与每个在它自己的OBX段中表示的医疗概念一起被表示。这些概念中的很多能被作为编码实体来表示。

1. ASSUMPTIONS

9.4 假设

Within this section, we have created a single message whose contents vary predicated on the trigger event. The following assumptions are made when the Medical Document Management (MDM) message is used:

在本节中，我们建立了一个单一的信息，该信息的内容在触发事件上有本质改变。当使用病历档案管理(MDM)信息的时候，设定以下的假设：

The application system is responsible for meeting all legal requirements (on the local, state, and federal levels) in the areas of document authentication, confidentiality, and retention.
应用程序系统对满足所有在档案鉴别，机密和保存领域内的合法要求（在本地的，州的，和联邦层的）负有责任。
All documents are unique, and document numbers and file names are not reused.
所有档案是唯一的，不重复使用档案号和文件名。
Documents may be associated with one or more orders.
档案可以与一个或多个指令相联系。
1. TRIGGER EVENTS AND MESSAGE DEFINITIONS

9.5 触发事件和信息定义

Each triggering event is listed below, along with the applicable form of the message exchange. The notation used to describe the sequence, optionality, and repetition of segments is described in Chapter 2, “Format for Defining Abstract Messages.” There are two classes of events, those which contain notifications only, and those which contain both notifications and content (text contained in OBX segments).

每个触发事件与信息交换的应用格式一起在下面被列出。用来描述段的顺序，可选性和副本的符号在第2章“定义抽象信息的格式”中有描述。事件有两类，一类仅包含符号；另一类同时包含符号和在OBX段中的文本内容。

These triggering events are mainly associated with documents or entries that will be or have been transcribed. The types and appearance of the transcribed documents can vary greatly within a healthcare organization and between organizations. However, the main purpose of the transcription process is to document patient care or diagnostic results in a legible manner; these documents then become part of the legal medical record. The conceptual purpose of document notification is to facilitate updating the receiving system(s) with information from the source system(s), typically dictation or transcription systems, to indicate that an electronic document has been created or altered. The document notification message can be attached to an entire document (i.e., transcribed document) or can be transmitted stand-alone. In either case, the document notification is transmitted in the form of an unsolicited update or in response to a record-oriented query. A document notification message can be created under a variety of circumstances such as when: 1) dictation has been completed; 2) a document has been transcribed; or 3) the status of a document has been changed, for example, when a document has been authenticated.

这些触发事件主要与将要或已经被转录的档案或输入项相联系。转录档案的类型和版面能够在一个医疗服务机构内和机构之间改变。但是，转录的主要目的是用清晰易读的方式对病人医疗服务或诊断的结果编档，这些档案成为合法的病历记录的一部分。档案通告在理论上的目的是促进使用原始资料系统的信息来更新接收系统，指出一个电子的档案已经被建立或改变，典型的原始资料系统为口述或转录系统。档案通告信息能被附加到一个实体档案上（如，转录档案）或能被独立地传送。在任一病例中，档案通告被在一个主动提供更新的版面中传送或回应一个记录导向的询问程序。一个档案通告信息能在各种各样的环境下被建立，如：1)当完成口述的时候；2)当完成转录一个档案的时候；3) 当改变一个档案的状态的时候，例如，当一个已经完成鉴别档案的时候。

1. 1. MDM/ACK - original document notification (event T01)

9.5.1 MDM/ACK – 原档案通告(事件码T01)

This is a notification of the creation of a document without the accompanying content. There are multiple approaches by which systems become aware of documents:

这是一个不包括伴随内容的档案创建的通告。系统察觉到档案有多个途径。

Scenario A: A document is dictated and chart tracking system is notified that it has been dictated and is awaiting transcription.

方案A: 口述A档案，图表跟踪系统被通知该档案已经被口述，并在等待转录。

Scenario B: Dictation is transcribed and chart tracking system is notified that the document exists and requires authentication.

方案B: 口述被转录，图表跟踪系统被通知该档案存在，并需要鉴别。

Scenario C: A provider orders a series of three X-rays. The radiologist dictates a single document which covers all three orders. Multiple placer numbers are used to identify each of these orders.

方案C: 医疗提供者开出三张X光射线的系列的单子。放射线治疗师口述一个单独的覆盖所有三张单子的档案。使用多个设置号码来分别识别三张单子。

MDM^T01^MDM_T01	Original Document Notification	Chapter
	原档案通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T01^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - original document notification and content (event T02)

9.5.2 MDM/ACK –原档案通告和内容（事件码T02）

This is a notification of the creation of a document with the accompanying content.

这是一个有伴随内容的档案创建的通告。

Scenario A: Dictation is transcribed and the chart tracking system is notified that the document exists and requires authentication. The content of the document is transmitted along with the notification.

方案 A: 转录口述，图表跟踪系统被通知该档案存在，并需要鉴别。档案的内容和该通告一起被传送。

Scenario B: A provider orders a series of three X-rays. The radiologist’s dictation is transcribed in a single document, which covers all three orders. Multiple placer numbers are used to identify each of the orders within the single document message. The notification and document content are transmitted.

方案 B: 医疗提供者开出三张X光射线的系列的单子。放射线治疗师在一个单一的覆盖所有三张单子的档案中的口述被转录。多个设置号码被用来分别识别在这单一档案信息中的三张单子。档案的内容和通告一起被传送。

MDM^T02^MDM_T02	Original Document Notification & Content	Chapter
	原档案通告和内容	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
{OBX}	Observation/Result (one or more required)	9
	观察报告/结果(必需一个或多个)

ACK^T02^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error Information	2
	错误信息

1. 1. MDM/ACK - document status change notification (event T03)

9.5.3 MDM/ACK – 档案状态改变通告（事件码T03）

This is a notification of a change in a status of a document without the accompanying content.

这是一个不包含伴随内容的一个档案的某个状态的改变通告。

Scenario: A document is authenticated. Notification is sent to the chart tracking system and is used to update the document status from pre-authenticated to authenticated or legally authenticated.

方案：鉴别A档案。通告被发送到图表跟踪系统，并被用来更新从鉴别前到完成鉴别或完成合法地鉴别的该档案的状态。

A change in any of the following independent status characteristics would cause a message to be sent:

对以下任何独立状态中的改变将发送一条信息。

Completion Status
完成状态
Confidentiality Status
机密状态
Availability Status (the Availability Status of “cancelled” is supported in T11 (document cancel notification) or T03)
有效状态（在T11（档案删除通告）或T03中支持“删除”的有效状态）
Storage Status
存储状态

MDM^T03^MDM_T01	Document Status Change Notification	Chapter
	档案状态改变通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T03^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document status change notification and content (event T04)

9.5.4 MDM/ACK –档案状态改变通告和内容(事件码T04)

This is a notification of a change in a status of a document with the accompanying content.

这是一个包含伴随内容的一个档案的某个状态的改变通告。

Scenario: A document is authenticated. Notification is sent to the chart tracking system and is used to update the document status from pre-authenticated to authenticated or legally authenticated. The document content is also transmitted.

方案：鉴别A档案。通告被发送到图表跟踪系统，并被用来更新从鉴别前到完成鉴别或完成合法地鉴别的该档案的状态。该档案的内容也被传送。

MDM^T04^MDM_T02	Document Status Change Notification & Content	Chapter
	档案状态改变通告和内容	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
{OBX}	Observation/Result (one or more required)	7
	观察报告/结果(必需一个或多个)

ACK^T04^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document addendum notification (event T05)

9.5.5 MDM/ACK –档案附录通告（事件码T05）

This is a notification of an addendum to a document without the accompanying content.

这是不包含伴随内容的一个档案的附录的通告。

Scenario: Author dictates additional information as an addendum to a previously transcribed document. A new document is transcribed. This addendum has its own new unique document ID that is linked to the original document via the parent ID. Addendum document notification is transmitted. This creates a composite document.

方案：档案制作者口述补充信息作为一个已经转录的档案的附录。转录一个新的档案。这个附录有它自己的新的唯一的档案ID，该ID通过原始ID与原档案相联接。附录档案通告被传送。这就创建了一个复合的档案。

MDM^T05^MDM_T01	Document Addendum Notification	Chapter
	档案附录通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T05^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document addendum notification and content (event T06)

9.5.6 MDM/ACK - 档案附录通告和内容(事件码T06)

This is a notification of an addendum to a document with the accompanying content.

这是包含伴随内容的一个档案的附录的通告。

方案：档案制作者口述补充信息作为一个已经转录的档案的附录。转录一个新的档案。这个附录有它自己的新的唯一的档案ID，该ID通过原始ID与原档案相联接。附录档案通告和档案内容一起被传送。这就创建了一个复合的档案。

MDM^T06^MDM_T02	Document Addendum Notification & Content	Chapter
	档案附录通告和内容	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
{OBX}	Observation/Result (one or more required)	7
	观察报告/结果(必需一个或多个)

ACK^T06^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document edit notification (event T07)

9.5.7 MDM/ACK - 档案编辑通告(事件码T07)

Note: The only valid use of this trigger event is for documents whose availability status is “Unavailable,” i.e., the document has not been made available for patient care.

注意: 这个触发事件的唯一有效应用是当档案的有效状态为“无效”时，例如，该档案对病人的医疗服务无效。

This is a notification of an edit to a document without the accompanying content.

这是编辑一个不包含伴随内容的档案的通告。

Scenario: Errors, which need to be corrected, are discovered in a document. The original document is edited, and an edit notification is sent.

方案：在一个档案中发现需要被纠正的错误。编辑原档案，并发送编辑通告。

MDM^T07^MDM_T01	Document Edit Notification	Chapter
	档案编辑通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T07^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document edit notification and content (event T08)

9.5.8 MDM/ACK - 档案编辑通告和内容(事件码T08)

Note: The only valid use of this trigger event is for documents whose availability status is "Unavailable," i.e., the document has not been made available for patient care.

注意: 这个触发事件的唯一有效应用是当档案的有效状态为“无效”时，例如，该档案对于病人的医疗服务无效。

This is a notification of an edit to a document with the accompanying content.

这是编辑一个包含伴随内容的档案的通告。

Scenario: Errors, which need to be corrected, are discovered in a document. The original document is edited, and an edit notification and document content are sent.

方案：在一个档案中发现需要被纠正的错误。编辑原档案，并发送编辑通告和档案内容。

MDM^T08^MDM_T02	Document Edit Notification & Content	Chapter
	档案编辑通告和内容	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
{OBX}	Observation/Result (one or more required)	7
	观察报告/结果(必需一个或多个)

ACK^T08^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document replacement notification (event T09)

9.5.9 MDM/ACK - 档案替换通告（事件码T09）

Note: This trigger event is generally used when the original document availability status is “Available.”

注意：这个触发事件通常被用在当原档案有效状态是“有效”的时候。

This is a notification of replacement to a document without the accompanying content.

这是替换一个不包含伴随内容的档案的通告。

Scenario: Errors discovered in a document are corrected. The original document is replaced with the revised document. The replacement document has its own new unique document ID that is linked to the original document via the parent ID. The availability status of the original document is changed to “Obsolete” but the original document should be retained in the system for historical reference. Document replacement notification is sent.

方案：纠正在一个档案中发现的错误。原档案被修改后的档案替换。替换档案有它自己的新的唯一的档案ID，该ID通过原始ID与原档案相联接。原档案的有效状态被改成“废弃”，但是原档案应该保留在系统中用作历史参考。档案替换通告被发送。

MDM^T09^MDM_T01	Document Replacement Notification	Chapter
	档案替换通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T09^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document replacement notification and content (event T10)

9.5.10 MDM/ACK - 档案替换通告和内容（事件码T10）

方案：纠正在一个档案中发现的错误。原档案被修改后的档案替换。替换档案有它自己的新的唯一的档案ID，该ID通过原始ID与原档案相联接。原档案的有效状态被改成“废弃”，但是原档案应该保留在系统中用作历史参考。档案替换通告和档案内容被发送。

MDM^T10^MDM_T02	Document Replacement Notification & Content	Chapter
	档案替换通告和内容	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
{OBX}	Observation/Result (one or more required)	7
	观察报告/结果(必需一个或多个)

ACK^T10^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. 1. MDM/ACK - document cancel notification (event T11)

9.5.11 MDM/ACK - 档案删除通告（事件码T11）

This is a notification of a cancellation of a document. This trigger event should be used only for an original document with an availability status of “Unavailable.” When a document has been made available for patient care, the process should be to replace the original document, which then becomes obsolete. The replacement document describes why the erroneous information exists.

这是一个档案删除的通告。该触发事件应该被仅用于一个有效状态为“无效”的原档案。当一个档案已经对病人的医疗服务生效时，该过程将替换原档案，原档案作废。替换档案描述了错误信息存在的原因。

Scenario: When the author dictated a document, the wrong patient identification was given, and the document was transcribed and sent to the wrong patient’s record. When the error is discovered, a cancellation notice is sent to remove the document from general access in the wrong patient’s record. In these cases, a reason should be supplied in the cancellation message. To protect patient privacy, the correct patient’s identifying information should not be placed on the erroneous document that is retained in the wrong patient’s record for historical reference. A new document notification and content will be created using a T02 (original document notification and content) event and sent for association with the correct patient’s record.

方案：当档案制作者口述一个档案的时候，给出了错误的病人识别符，该档案被转录并被发送到错误的病人记录中。当这个错误被发现，一个删除通知被发送以通过常规途径删去在错误的病人记录中的档案。为了保护病人的隐私，正确的病人的识别信息不应该被放置在错误的档案中，也就是仍保留在错误的病人记录中用作历史参考。一个新的档案通告和内容将使用事件码T02（原档案通告和内容）来创建，并与正确的病人记录相联系。

MDM^T11^MDM_T01	Document Cancel Notification	Chapter
	档案删除通告	章别
MSH	Message Header	2
	信息标头
EVN	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告

ACK^T11^ACK	General Acknowledgment	Chapter
	一般确认	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgment	2
	信息确认
[ERR]	Error	2
	错误信息

1. MESSAGE SEGMENTS

9.6 信息段

1. 1. TXA - transcription document header segment

9.6.1 TXA - 转录档案标题段

The TXA segment contains information specific to a transcribed document but does not include the text of the document. The message is created as a result of a document status change. This information is used to update other healthcare systems to identify reports that are available in the transcription system. By maintaining the TXA message information in these systems, the information is available when constructing queries to the transcription system requesting the full document text.

TXA段包含仅限于一个已转录的档案的信息，但不包括该档案的文本。该信息作为一个档案状态改变的结果被创建。这个信息被用来更新其他医疗服务系统以识别在转录系统中有效的报告书。通过在这些系统中保留TXA信息，当对转录系统构建询问程序需要全部档案文本的时候，可以使用这些信息。

HL7 Attribute Table – TXA – Transcription Document Header

HL7属性表– TXA –转录档案标题

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME
							成分名称
1	4	SI	R			00914	Set ID- TXA
							设置ID- TXA
2	30	IS	R		0270	00915	Document Type
							档案类型
3	2	ID	C		0191	00916	Document Content Presentation
							档案内容陈述
4	26	TS	O			00917	Activity Date/Time
							活动日期/时间
5	250	XCN	C	Y		00918	Primary Activity Provider Code/Name
							主要活动提供者代码/姓名
6	26	TS	O			00919	Origination Date/Time
							创建日期/时间
7	26	TS	C			00920	Transcription Date/Time
							转录日期/时间
8	26	TS	O	Y		00921	Edit Date/Time
							编辑日期/时间
9	250	XCN	O	Y		00922	Originator Code/Name
							创建者代码/姓名
10	250	XCN	O	Y		00923	Assigned Document Authenticator
							指定的档案鉴别人
11	250	XCN	C	Y		00924	Transcriptionist Code/Name
							转录者代码/姓名
12	30	EI	R			00925	Unique Document Number
							唯一的档案号码
13	30	EI	C			00926	Parent Document Number
							原始档案号码
14	22	EI	O	Y		00216	Placer Order Number
							放置器指令号码
15	22	EI	O			00217	Filler Order Number
							填充符指令号码
16	30	ST	O			00927	Unique Document File Name
							唯一的档案文件名称
17	2	ID	R		0271	00928	Document Completion Status
							档案完成状态
18	2	ID	O		0272	00929	Document Confidentiality Status
							档案机密状态
19	2	ID	O		0273	00930	Document Availability Status
							档案有效状态
20	2	ID	O		0275	00932	Document Storage Status
							档案存储状态
21	30	ST	C			00933	Document Change Reason
							档案改变理由
22	250	PPN	C	Y		00934	Authentication Person, Time Stamp
							鉴别人，时间标记
23	250	XCN	O	Y		00935	Distributed Copies (Code and Name of Recipients)
							复印件的分发（接收者的代码和名称）

1. 1. 1. TXA field definitions

9.6.1.0 TXA字段定义

1. 1. 1. TXA-1 Set ID - TXA (SI) 00914

9.6.1.1 TXA-1 设置ID - TXA (SI) 00914

Definition: This field contains a number that uniquely identifies this transaction for the purpose of adding, changing, or deleting the transaction.

定义：这个字段包含一个唯一地识别对这个处理事项进行增加，改变，或删除等处理的号码。

1. 1. 1. TXA-2 Document type (IS) 00915

9.6.1.2 TXA-2 档案类型 (IS) 00915

Definition: This field identifies the type of document (as defined in the transcription system). Refer to User-defined Table 0270 - Document type for suggested values. The organization is free to add more entries.

定义：这个字段标识档案的类型（与在转录系统中定义的一样）。相关建议值请参考用户定义表0270 – 档案类型。机构可以自由增加更多的项目。

User-defined Table 0270 – Document type

用户定义表0270 – 档案类型

Value	Description
值	描述
AR	Autopsy report
	尸体解剖报告书
CD	Cardiodiagnostics
	心脏诊断
CN	Consultation
	会诊
DI	Diagnostic imaging
	诊断成像
DS	Discharge summary
	摘要
ED	Emergency department report
	急诊科报告
HP	History and physical examination
	病历和身体检查
OP	Operative report
	手术报告
PC	Psychiatric consultation
	精神病治疗会诊
PH	Psychiatric history and physical examination
	精神病历和身体检查
PN	Procedure note
	程序笔记
PR	Progress note
	进展笔记
SP	Surgical pathology
	外科病理学
TS	Transfer summary
	转院摘要

1. 1. 1. TXA-3 Document content presentation (ID) 00916

9.6.1.3 TXA-3 档案内容陈述(ID) 00916

Definition: This is a conditional field which is required whenever the message contains content as presented in one or more OBX segments. This field identifies the method by which this document was obtained or originated. Refer to HL7 Table 0191 – Type of referenced data for valid values.

定义：这是一个有条件的字段，只要信息包含一个或多个OBX段中的内容，就需要本字段。本字段标识获得或创建这个档案的方法。请参考HL7表0191 – 引用的数据的类型的有效值。

HL7 Table 0191 - Type of referenced data

HL7表0191 – 引用的数据的类型

Value	Description
值	描述
AP	Other application data, typically uninterpreted binary data (HL7 V2.3 and later)
	其他应用程序数据，典型的非解释的二进位的数据（HL7 V2.3及以后的版本）
AU	Audio data (HL7 V2.3 and later)
	音频数据（HL7 V2.3及以后的版本）
FT	Formatted text (HL7 V2.2 only)
	格式化文本（仅HL7 V2.2版）
IM	Image data (HL7 V2.3 and later)
	图像数据（HL7 V2.3及以后的版本）
multipart	MIME multipart package
	MIME 软件包
NS	Non-scanned image (HL7 V2.2 only)
	非扫描的图像（仅HL7 V2.2版）
SD	Scanned document (HL7 V2.2 only)
	扫描的文档（仅HL7 V2.2版）
SI	Scanned image (HL7 V2.2 only)
	扫描的图像（仅HL7 V2.2版）
TEXT	Machine readable text document (HL7 V2.3.1 and later)
	机读文本文档（HL7 V2.3.1及以后的版本）
TX	Machine readable text document (HL7 V2.2 only)
	机读文本文档（仅HL7 V2.2版）

1. 1. 1. TXA-4 Activity date/time (TS) 00917

9.6.1.4 TXA-4 活动日期/时间 (TS) 00917

Definition: This field contains the date/time identified in the document as the date a procedure or activity was performed. This date can identify date of surgery, non-invasive procedure, consultation, examination, etc.

定义：这个字段包含在档案中作为执行一个程序或活动的日期识别的日期/时间。这个日期可以识别手术的，非扩散程序的，会诊的和临床检验等的日期。

1. 1. 1. TXA-5 Primary activity provider code/name (XCN) 00918

9.6.1.5 TXA-5 主要活动提供者代码/姓名 (XCN) 00918

Components: In Version 2.3 and later, use instead of the CN data type. <ID number (ST)> ^ <family name (FN)> ^ <given name (ST)> ^ <second and further given names or initials thereof (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (IS)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code (ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)> ^ <name representation code (ID)> ^ <name context (CE)> ^ <name validity range (DR)> ^ < name assembly order (ID)>

组成：在2.3及以后的版本中，替代CN数据类型。<ID 号码 (ST)> ^<姓(FN)> ^ <名字(ST)> ^ <第二和除此外的名字或者名字中的大写字母 (ST)> ^ <后缀 (例如，JR or III) (ST)> ^前缀 (例如，DR) (ST)> ^ <学位 (例如, 硕士) (IS)> ^ <原始资料表 (IS)> ^ <授权证明 (HD)> ^ <名称类型代码 (ID)> ^<校验数位标识符 (ST)> ^ <识别已采用的校验数位方案的代码 (ID)> ^ <类型代码标识符 (IS)> ^ <指定设施 (HD)> ^ <名称代表代码 (ID)> ^ <名称环境 (CE)> ^ <名称有效范围 (DR)> ^ <名称汇编顺序 (ID)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This field contains the name of the person identified in the document as being responsible for performing the procedure or activity. This field includes the code and name (if available) of the caregiver. This field is conditional based upon the presence of a value in TXA-4-Activity date/time.

定义：这个字段包含在档案中识别负责执行程序或活动的人的姓名。本字段包括该医疗服务提供者的代码和姓名（如果有效）。本字段建立的条件是在TXA-4-活动日期/时间中的某个值的存在的基础上。

1. 1. 1. TXA-6 Origination date/time (TS) 00919

9.6.1.6 TXA-6 创建日期/时间(TS) 00919

Definition: This field contains the date and time the document was created (i.e., dictated, recorded, etc.).

定义：这个字段包含档案创建的日期和时间（如：口述，记录等）。

1. 1. 1. TXA-7 Transcription date/time (TS) 00920

9.6.1.7 TXA-7 转录日期/时间(TS) 00920

Definition: This field contains the date and time the input was actually transcribed. This field is conditional based upon the presence of a value in TXA-17-Document completion status of anything except “dictated.”

定义：这个字段包含输入被有效地转录的日期和时间。本字段有条件地建立在除了“口述”以外的在TXA-17-档案完成状态中的某个值存在的基础上。

1. 1. 1. TXA-8 Edit date/time (TS) 00921

9.6.1.8 TXA-8 编辑日期/时间(TS) 00921

Definition: This field contains the date and time the document was edited.

定义：这个字段包含档案被编辑的日期和时间。

1. 1. 1. TXA-9 Originator code/name (XCN) 00922

9.6.1.9 TXA-9 创建者代码/姓名 (XCN) 00922

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This field identifies the person who originated (i.e., dictated) the document. The document originator may differ from the person responsible for authenticating the document.

定义：这个字段标识创建档案（如：口述）的人。该档案创建者可以不同于负责鉴别该档案的人。

1. 1. 1. TXA-10 Assigned document authenticator (XCN) 00923

9.6.1.10 TXA-10 指定的档案鉴别人 (XCN) 00923

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This field identifies the person(s) responsible for authenticating the document, who may differ from the originator. Multiple persons may be responsible for authentication, especially in teaching facilities. This field is allowed to repeat an undefined number of times.

定义：这个字段标识负责鉴别档案的人，此人可以不同于创建档案的人。可以有多个人对鉴别负责，尤其是在教学机构中。允许本字段重复一个次数的未定义的号码。

1. 1. 1. TXA-11 Transcriptionist code/name (XCN) 00924

9.6.1.11 TXA-11 转录者代码/姓名 (XCN) 00924

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This field identifies the person transcribing the document. This is a conditional value; it is required on all transcribed documents.

定义：这个字段标识转录档案的人。这是一个有条件的值，在所有被转录的档案中都需要它。

1. 1. 1. TXA-12 Unique document number (EI) 00925

9.6.1.12 TXA-12 唯一的档案号码 (EI) 00925

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (st)> ^ <universal ID type (ID)>

组成：<实体标识符 (ST)> ^ <场所名称ID (IS)> ^ <通用ID (ST)> ^ <通用ID类型 (ID) >

Definition: This field contains a unique document identification number assigned by the sending system. This document number is used to assist the receiving system in matching future updates to the document, as well as to identify the document in a query. When the vendor does not provide a unique document ID number, some type of document identifier should be entered here, or the Unique Document File name should be utilized. See Chapter 2, Section 2.9.55, “XTN - extended telecommunication number.” Where the system does not customarily have a document filler number, this number could serve as that value, as well.

定义：这个字段包含一个由发送系统指定的唯一的档案识别号码。这个档案号码被用来协助接收系统与将来对该档案的更新相匹配，以及在一个询问程序中识别该档案。当卖主不提供一个唯一的档案ID号码的时候，应该在这里输入档案标识符的某些类型，或者应该使用唯一的档案文件名称。参看第2章，2.9.55节“XTN – 扩展的电信号吗”。通常在系统没有档案填充符号码的地方，本号码也可以被用作那个值。

1. 1. 1. TXA-13 Parent document number (EI) 00926

9.6.1.13 TXA-13 原始档案号码 (EI) 00926

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

组成：<实体标识符 (ST)> ^ <场所名称ID (IS)> ^ <通用ID (ST)> ^ <通用ID类型 (ID) >

Definition: This field contains a document number that identifies the parent document to which this document belongs. The parent document number can be used to assist the receiving system in matching future updates to this document. This is a conditional field that is always required on T05 (document addendum notification), T06 (document addendum notification and content), T09 (document replacement notification), and T10 (document replacement notification and content) events.

定义：这个字段包含识别该档案的原始档案的一个档案号码。原始档案号码能被用来协助接收系统与将来对该档案的更新相匹配。这是一个有条件的字段，在事件码T05（档案附录通告）， T06（档案附录通告和内容）， T09（档案替换通告），和T10（档案替换通告和内容）中始终需要本字段。

1. 1. 1. TXA-14 Placer order number (EI) 00216

9.6.1.14 TXA-14 放置器指令号码 (EI) 00216

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

组成：<实体标识符 (ST)> ^ <场所名称ID (IS)> ^ <通用ID (ST)> ^ <通用ID类型 (ID) >

Definition: This field is the placer application’s order number.

定义：这个字段是放置器应用程序的指令号码。

This is a composite field. The first component is a string of characters that identifies an individual order (e.g., OBR). It is assigned by the placer (ordering application). It identifies an order uniquely among all orders from a particular ordering application. The second through fourth components contain the (filler) assigning authority of the placing application. The (filler) assigning authority is a string of characters that will be uniquely associated with an application. A given institution or group of intercommunicating institutions should establish a unique list of applications that may be potential placers and fillers and assign unique entity identifiers. The components are separated by component delimiters.

这是一个复合字段。第一组成成分是识别一个单独的指令的一串字符（如：OBR）。它是由放置器（指令应用程序）指定的。它从某个特殊的指令应用程序中的所有指令里唯一识别一个指令。第二至第四组成成分包含放置应用程序的赋值权限（填充符）。赋值权限（填充符）是唯一与一个应用程序相连的一串字符。机构应该设立一个应用程序的唯一的列表，该列表可以是潜在的放置器，填充符和指定的唯一的实体标识符。这些组成成分由组成成分的分隔符来分隔。

1. 1. 1. TXA-15 Filler order number (EI) 00217

9.6.1.15 TXA-15 填充符指令号码 (EI) 00217

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

组成：<实体标识符 (ST)> ^ <场所名称ID (IS)> ^ <通用ID (ST)> ^ <通用ID类型 (ID) >

Definition: This field is the order number associated with the filling application. Where a transcription service or similar organization creates the document and uses an internally unique identifier, that number should be inserted in this field. Its first component is a string of characters that identifies an order detail segment (e.g., OBR). This string must uniquely identify the order (as specified in the order detail segment) from other orders in a particular filling application (e.g., transcription service). This uniqueness must persist over time. Where a number is reused over time, a date can be affixed to the non-unique number to make it unique.

定义：这个字段是与填充应用程序相连的指令号码。在转录服务机构或类似的机构创建档案和使用一个内部唯一的标识符的地方，该号码应该被插入在这个字段中。它的第一组成成分是识别一个指令细节段（如：OBR）的一串字符。这串字符必须从一个特殊的填充应用程序（如：转录服务）中的其他指令里唯一识别该指令（作为在指令细节段中指定的）。该唯一性必须超时持续。在一个号码被再次超时使用的地方，在非唯一的号码上附上日期以使其成为唯一。

The second through fourth components contains the (filler) assigning authority. The (filler) assigning authority is a string of characters that uniquely defines the application from other applications on the network. The second through fourth components of the filler order number always identify the actual filler of an order.

第二至第四的组成成分包含赋值权限（填充符）。该赋值权限（填充符）是唯一地定义在网络上的其他应用程序中的应用程序的一串字符。填充符指令号码的第二至第四的组成成分始终识别一个指令的现行的填充符。

For further details, please see the definitions provided in Chapter 4.

请参看第4章提供的定义以获得更多的详细资料。

1. 1. 1. TXA-16 Unique document file name (ST) 00927

9.6.1.16 TXA-16 唯一的档案文件名称 (ST) 00927

Definition: This field contains a unique name assigned to a document by the sending system. The file name is used to assist the receiving system in matching future updates to the document.

定义：这个字段包含一个由发送系统指定的档案的唯一的名称。该文件名称被用来协助接收系统与将来对该档案的更新相匹配。

1. 1. 1. TXA-17 Document completion status (ID) 00928

9.6.1.17 TXA-17 档案完成状态 (ID) 00928

Definition: This field identifies the current completion state of the document. This is a required, table-driven field. Refer to HL7 table 0271 - Document completion status for valid values.

定义：这个字段识别档案的当前完成状态。这是一个必需的字段。请参考HL7表0271 – 档案完成状态的有效值。

HL7 Table 0271 - Document completion status

HL7表0271 – 档案完成状态

Value	Description
值	描述
DI	Dictated
	完成口述
DO	Documented
	完成编档
IP	In Progress
	操作中
IN	Incomplete
	未完成
PA	Pre-authenticated
	鉴别前
AU	Authenticated
	完成鉴别
LA	Legally authenticated
	完成合法地鉴别

Figure 9-1. Document completion status state transition table

图表9-1. 档案完成状态的状态转换表

Transition (Action)	Old State	New State
T01 Original Notification T01原档案通告 T02 Original Notification and Content T01原档案通告和内容	NA	Dictated 完成口述 In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
T03 Status Change Notification T03状态改变通告 T04 Status Change Notification and Content T04状态改变通告和内容	Dictated 完成口述	In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	In Progress 操作中	Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Incomplete 未完成	Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Pre-authenticated 鉴别前	Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Authenticated 完成鉴别	Legally authenticated 完成合法地鉴别
	Legally authenticated 完成合法地鉴别	NA
	Documented 完成编档	Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
T05 Addendum Notification T05附录通告 T06 Addendum Notification and Content T06附录通告和内容	NA	Dictated 完成口述 In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
T07 Edit Notification T07编辑通告 T08 Edit Notification and Content T08编辑通告和内容	Dictated 完成口述	In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	In Progress 操作中	Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Incomplete 未完成	Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Pre-authenticated 鉴别前	Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
	Authenticated 完成鉴别	Legally authenticated 完成合法地鉴别
	Legally authenticated 完成合法地鉴别	NA
	Documented 完成编档	Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
T09 Replacement Notification T09替换通告 T10 Replacement Notification and Content T10替换通告和内容	NA	Dictated 完成口述 In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 Authenticated 完成鉴别 Legally authenticated 完成合法地鉴别
T11 Cancel Notification T11删除通告	Dictated 完成口述 In Progress 操作中 Incomplete 未完成 Pre-authenticated 鉴别前 and Availability status of “Unavailable” 和“无效”的有效状态	Canceled 已删除

Transition (Action)

Old State

New State

转换（方式）

旧状态

新状态

T01 Original Notification

T01原档案通告

T02 Original Notification and Content

T01原档案通告和内容

Dictated

完成口述

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

T03 Status Change Notification

T03状态改变通告

T04 Status Change Notification and Content

T04状态改变通告和内容

Dictated

完成口述

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Legally authenticated

完成合法地鉴别

Documented

完成编档

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

T05 Addendum Notification

T05附录通告

T06 Addendum Notification and Content

T06附录通告和内容

Dictated

完成口述

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

T07 Edit Notification

T07编辑通告

T08 Edit Notification and Content

T08编辑通告和内容

Dictated

完成口述

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

Legally authenticated

完成合法地鉴别

Documented

完成编档

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

T09 Replacement Notification

T09替换通告

T10 Replacement Notification and Content

T10替换通告和内容

Dictated

完成口述

In Progress

操作中

Incomplete

未完成

Pre-authenticated

鉴别前

Authenticated

完成鉴别

Legally authenticated

完成合法地鉴别

T11 Cancel Notification

T11删除通告

Dictated

完成口述
In Progress

操作中
Incomplete

未完成
Pre-authenticated

鉴别前
and Availability status of “Unavailable”

和“无效”的有效状态

Canceled

已删除

Note: NA means not applicable. Document confidentiality status (ID) 00929

注意： NA表示不可应用。档案机密状态(ID) 00929

1. 1. 1. TXA-18 Document confidentiality status (ID) 00929

9.6.1.18 TXA-18 档案机密状态 (ID) 00929

Definition: This is an optional field which identifies the degree to which special confidentiality protection should be applied to this information. The assignment of data elements to these categories is left to the discretion of the healthcare organization. Refer to HL7 table 0272 - Document confidentiality status for valid values.

定义：这是一个识别对信息应该进行机密保护的专门级别的可选性的字段。由医疗服务机构来判断对这些种类的数据元素的指定。请参考HL7表0272 -档案机密状态的有效值。

HL7 Table 0272 - Document confidentiality status

HL7表0272 -档案机密状态

Value	Description
值	描述
V	Very restricted
	非常机密
R	Restricted
	机密
U	Usual control
	一般控制

1. 1. 1. TXA-19 Document availability status (ID) 00930

9.6.1.19 TXA-19 档案有效状态(ID) 00930

Definition: This is an optional field which identifies a document’s availability for use in patient care. If an organization’s business rules allow a document to be used for patient care before it is authenticated, the value of this field should be set to “AV.” If a document has been made available for patient care, it cannot be changed or deleted. If an erroneous document has been made available at any point in time and a replacement is not appropriate, then it may be marked as “Canceled” and removed, as in the case of a document being assigned to the wrong patient. Additional information must be provided via an addendum, which is separately authenticated and date/time stamped. If the content of a document whose status is “Available” must be revised, this is done by issuing a replacement, which is separately authenticated and date/time stamped. Refer to HL7 table 0273 - Document availability status for valid values.

定义：这是识别一个档案对病人医疗服务的有效性的可选性的字段。如果一个机构的经营规则允许一个档案在被鉴别前用于病人的医疗服务，此时本字段的值应被设为“AV”。如果已经设立了一个档案，对病人的医疗服务有效，该档案不能被改变或删除。如果一个错误的档案已经被设立为有效并且替换档案也不适用，与档案被指定给错误的病人的案例一样，该档案可以被标记为“删除”并被删去。附加信息必须通过一个附录档案来提供，该附录档案被单独地鉴别和标记日期/时间。如果必须修改状态标记为“有效”的档案的内容，则通过发送一个替换档案来完成，该替换档案被单独地鉴别和标记日期/时间。请参考HL7表0273 –档案有效状态有效值。

HL7 Table 0273 - Document availability status

HL7表0273 –档案有效状态

Value	Description
值	描述
AV	Available for patient care
	对病人医疗有效
CA	Deleted
	删除
OB	Obsolete
	废弃
UN	Unavailable for patient care
	对病人医疗无效

Figure 9-2. Document availability status state transition table

图表9-2. 档案有效状态的状态转换表

Transition (Action)	Old State	New State	Notes
转换（方式）	旧状态	新状态	注意
T01 Original Notification T01 原档案通告 T02 Original Notification and Content T02原档案通告和内容	NA	Unavailable 无效 Available 有效
T03 Status Change Notification T03状态改变通告 T04 Status Change Notification and Content T04状态改变通告和内容	Unavailable 无效	Unavailable 无效 Available 有效 Obsolete 废弃
	Available 有效	Available 有效 Obsolete 废弃
	Obsolete 废弃	NA
T05 Addendum Notification T05附录通告 T06 Addendum Notification and Content T06附录通告和内容	NA	Unavailable 无效 Available 有效
T07 Edit Notification T07编辑通告 T08 Edit Notification and Content T08编辑通告和内容	Unavailable 无效	Unavailable 无效 Available 有效
T09 Replacement Notification T09替换通告 T10 Replacement Notification and Content T10替换通告和内容	NA	Unavailable 无效 Available 有效	Set parent document to "obsolete" 设置原始档案为“废弃”
T11 Cancel T11删除	Unavailable 无效	Delete 删除

Note: NA means not applicable.

注意： NA表示不可应用。

1. 1. 1. TXA-20 Document storage status (ID) 00932

9.6.1.20 TXA-20 档案存储状态(ID) 00932

Definition: This optional field identifies the storage status of the document. Refer to HL7 table 0275 - Document storage status for valid values.

定义：这个可选性的字段标识文档的存储状态。请参考HL7表0275 –档案存储状态的有效值。

HL7 Table 0275 - Document storage status

HL7表0275 –档案存储状态

Value	Description
值	描述
AC	Active
	当前的
AA	Active and archived
	当前和存档的
AR	Archived (not active)
	存档的（非当前的）
PU	Purged
	清除

1. 1. 1. TXA-21 Document change reason (ST) 00933

9.6.1.21 TXA-21档案改变理由(ST) 00933

Definition: This free text field (limited to 30 characters) contains the reason for document status change.

定义：这个自由文本字段（限制在30个字符内）包含文档状态改变的理由。

1. 1. 1. TXA-22 Authentication person, time stamp (set) (PPN) 00934

9.6.1.22 TXA-22 鉴别人，时间标记（设置） (PPN) 00934

Components: <ID number (ST)> ^ <family name (FN)> ^ <given name (ST) ^ <second and further given names or initials thereof (ST)>^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (IS)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID )> ^ <identifier type code (IS)> ^ <assigning facility (HD)> ^ < date/time action performed (TS)> ^ <name representation code (ID)> ^ <name context (CE)> ^ <name validity range (DR)> ^ <name assembly order (ID)>

Definition: This is a conditional field. When the status of TXA-17-Document completion status is equal to AU (authenticated) or LA (legally authenticated), all components are required. This field contains a set of components describing by whom and when authentication was performed. Whenever any one of the ID number - Name type code components is valued, the when authenticated component, which is time stamp, must be valued as non-null. If the time component of a set is valued as non-null, the person component becomes required. These subcomponents are normally delimited by an ampersand (&). See Chapter 2.

定义：这是一个有条件的字段。当TXA-17-档案完成状态的状态与AU（完成鉴别）或LA（完成合法地鉴别）相同时，需要所有的组成成分。本字段包含通过执行鉴别的人和时间来描述一组组成成分。只要任意一个ID号码和名称类型的代码组成成分被赋值，何时鉴别组成，及时间标记，必须被赋非零值。如果时间组成成分集被赋非零值，则需要人员组成成分。这些子组成成分通常由记号(&)来定界限。参看第2章。

1. 1. 1. 1. Authentication person (component) (XCN)

9.6.1.22.1 鉴别人（组成）(XCN)

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This component identifies the person who has authenticated the document (either manually or electronically).

定义：本组成成分识别鉴别档案的人（或者手写地或者电子地）。

1. 1. 1. 1. Authentication time stamp (component) (TS)

9.6.1.22.2 鉴别时间标记（组成） (TS)

Definition: This component contains the date and time the document was authenticated (either manually or electronically).

定义：本组成成分包含档案被鉴别的日期和时间（或者手写地或者电子地）。

1. 1. 1. TXA-23 Distributed copies (XCN) 00935

9.6.1.23 TXA-23 复印件的分发 (XCN) 00935

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

授权证明的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)>

指定设施的组成：<场所名称ID (IS)> & <通用ID (ST)> & <通用ID类型 (ID) >

Definition: This field identifies the persons who received a copy of this document.

定义：这个字段识别档案的复印件的接收人。

1. 1. OBX - observation segment usage

9.6.2 OBX -观察报告段用法

The OBX segment is documented in its entirety in Chapter 7. Its usage as it applies to Medical Records/ Information Management is documented here for clarity.

OBX段在第7章的它的项目中被编档。它在这里被编档是为了明确作为适用于病历档案/信息管理的用法。

HL7 Attribute Table - OBX – Observation Segment

HL7属性表- OBX –观察报告段

SEQ	LEN	DT	OPT	RP/#	TBL#	ITEM#	ELEMENT NAME
							成分名称
1	4	SI	R			00569	Set ID- OBX
							设置ID- OBX
2	2	ID	R		0125	00570	Value Type
							值类型
3	250	CE	O			00571	Observation Identifier
							观察报告标识符
4	20	ST	O			00572	Observation Sub-Id
							观察报告Sub-Id
5	*	*	C/R			00573	Observation Value
							观察报告值
6	250	CE	O			00574	Units
							单位
7	60	ST	O			00575	References Range
							参考范围
8	5	ID	O	Y/5	0078	00576	Abnormal Flags
							反常标记
9	5	NM	O			00577	Probability
							概率
10	2	ID	O		0080	00578	Nature of Abnormal Test
							反常的检验的种类
11	1	ID	R/NA		0085	00579	Observation Result Status
							观察报告结果状态
12	26	TS	C			00580	Date Last Observation Normal Values
							最近观察报告正常值
13	20	ST	C			00581	User Defined Access Checks
							用户定义数据库检验
14	26	TS	O			00582	Date/Time of Observation
							观察报告的日期/时间
15	250	CE	C			00583	Producer’s ID
							制作人ID
16	250	XCN	O	Y		00584	Responsible Observer
							责任观察员
17	250	CE	O	Y		00936	Observation Method
							观察报告方法

C = For fields OBX-12, OBX-13, and OBX-15, the field should be valued conditionally. These fields should be valued only when the result (OBX-5-observation value) contains a single concept. This is typically true when the result type is numeric, ID, or CE. When multiple medical concepts are expressed, the values of these three fields are ambiguous.* = 256 K or site negotiated

C =对字段OBX-12, OBX-13和OBX-15，该字段应被有条件地赋值。当结果（OBX-5-观察报告值）包含一个单一的概念的时候，应仅对这些字段赋值。当结果类型是数字的，ID，或 CE的时候，这是一个典型的状态。当表达了多个医疗观点的时候，这三个字段的值是不明确的。* = 256 K或协商位置

Specialized usage: Observation Identifier/Observation Sub-ID have been used as optional fields that are not required in unstructured text where the nature of the document has been identified in TXA-2-Document type, which is a required field, but is expressly allowed in the richer structured documentation. An example includes cases where anatomic reports may have separate OBXs for gross examination, microscopic examination, clinical impression, and final diagnosis. Another possible use includes imbedding non-textual observations within textual reports.

特殊用法：观察报告标识符/观察报告次ID已经被用作可选型的字段，在没有结构的文本中不需要这些字段，那些文本里档案类型已经在TXA-2-档案类型中被识别，但是在结构复杂的文档编制中特别地需要这些字段。一个实例包括在案例里解剖报告可能对总体检查，微观检查，临床分析和最终诊断分隔多个OBX。另一个可能的用法包括在原文报告中嵌入非原文的观察报告。

1. EXAMPLE MESSAGE

9.7 实例信息

The following is an example of an original transmission of a history and physical examination which has been authenticated prior to this message being initiated:

以下是优先于启动信息的病历和身体检查的最初传送的一个实例：

MSH|...<cr>

EVN|T02|19960215154405||04|097220^Smith^Frederick^A^Jr^Dr^MD^| <cr>

PID|...<cr>

PR1|...<cr>

TXA|0001|HP^history & physical|TX^text|19960213213000|099919^Tracy^Wayne^R^III^Mr^MS^|
19960213153000|19960215134500||099919^Tracy^Wayne^R^III^Mr^MS^|097220^Smith^Frederick^A^Jr^Dr^MD^|01234567^Baxter^Catherine^S^Ms|1996021500001^transA|||example.doc|LA|UC|AV||AC|||||097220^Smith^Frederick^A^Jr^Dr^MD^| <cr>

OBX|1|CE|2000.40^CHIEF COMPLAINT|| ... <cr>

OBX|2|ST|2000.01^SOURCE||PATIENT <cr>

OBX|3|TX|2000.02^PRESENT ILLNESS||SUDDEN ONSET OF CHEST PAIN. 2 DAYS, PTA ASSOCIATED WITH NAUSEA, VOMITING & SOB. NO RELIEF WITH ANTACIDS OR NTG. NO OTHER SX. NOT PREVIOUSLY ILL.<cr>

and so on.

等等。

1. QUERY

9.8 询问程序

A query may be used to retrieve a list of documents or a specific document. See Chapter 5 for details of queries.

一个询问程序可以被用来检索档案的列表或某个特殊的档案。参考第5章询问程序的详细资料。

1. 1. QRY/DOC - document query (event T12)

9.8.1 QRY/DOC – 档案询问程序（事件码T12）

QRY^T12	Document Query	Chapter
	档案询问程序	章别
MSH	Message Header	2
	信息标头
QRD	Query Definition	2
	询问程序定义
[ QRF ]	Query Filter	2
	询问程序筛选

DOC^T12	Document Response	Chapter
	档案应答	章别
MSH	Message Header	2
	信息标头
MSA	Message Acknowledgement	2
	信息确认
[ERR]	Error	2
	错误信息
[QAK]	Query Acknowledgement	5
	询问程序确认
QRD	Query Definition	2
	询问程序定义
{
[EVN]	Event Type	3
	事件类型
PID	Patient Identification	3
	病人身份识别
PV1	Patient Visit	3
	病人就诊
TXA	Document Notification	9
	档案通告
[{OBX}]	Observation	7
}	观察报告
[DSC]	Continuation Pointer	2
	连续指示器

1. 1. 1. hiddentext
    2. Query usage notes

9.8.1.1 询问程序用法注意事项

The QRD and QRF segments are defined in Chapter 5, Sections 5.10.5.3, “QRD - original style query definition segment,” and 5.10.5.4, “QRF - original style query filter segment.”

QRD和QRF段在第5章，5.10.5.3节，“QRD -原类型的询问程序定义段”和5.10.5.4节，“QRD -原类型的询问程序筛选段”中被定义。

The subject filters contained in the QRD and QRF segments describe the kind of information that is required to satisfy the request. They are defined by local agreement between the inquiring system and the ancillary system. See the Implementation Guide for detailed examples of the use of query filter fields.

在QRD和QRF段中主题筛选描述了满足要求所需的信息的类型。它们通过在咨询系统和子系统之间的本地协议来定义。参看询问程序筛选字段的使用具体实例的执行向导。

The Set ID fields in the various segments (including PID) are used to count the number of segments of one kind transmitted at one level of the hierarchy.

使用在各种段（包括PID）中的设置ID字段来计算在该层次的一个级别里传送的某类段的数量。

QRD-12-Query results level determines the amount of data requested. See Chapter 2, Section 5.10.5.3.12, “Query results level.”

QRD-12-询问程序结果层次决定了需要数据的数量。参看第2章，5.10.5.3.12节，“询问程序结果层次”。