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资源简介
ICS 11.020
CCS C 07
WS
中华人民共和国卫生行业标准
WS/T 846.8—2024
医院信息平台交互标准
第8 部分:医嘱信息交互服务
Hospital information platform interactive standard—
Part 8:Order information interactive services
2024 - 10 - 28 发布2025 - 04 - 01 实施
中华人民共和国国家卫生健康委员会 发布
WS/T 846.8-2024
I
前言
本标准是WS/T 846《医院信息平台交互标准》的第8部分。WS/T 846已经发布以下部分:
——第1部分:总则
——第2部分:个人信息注册、查询服务;
——第3部分:医疗卫生机构注册、查询服务;
——第4部分:医疗卫生人员注册、查询服务;
——第5部分:术语注册、查询服务;
——第6部分:文档注册、查询服务;
——第7部分:就诊信息交互服务;
——第8部分:医嘱信息交互服务;
——第9部分:申请单信息交互服务;
——第10部分:预约信息交互服务;
——第11部分:状态信息交互服务。
本标准由国家卫生健康标准委员会卫生健康信息标准专业委员会负责技术审查和技术咨询,由国家
卫生健康委统计信息中心负责协调性和格式审查,由国家卫生健康委规划发展与信息化司负责业务管
理、法规司负责统筹管理。
本标准主要起草单位:国家卫生健康委统计信息中心、重庆大学、大连大学附属中山医院、国家电
子计算机质量检验检测中心。
本标准主要起草人:董方杰、李岳峰、张翔、郑良、钟代笛、刁晓东。
WS/T 846.8-2024
1
医院信息平台交互标准第8 部分:医嘱信息交互服务
1 范围
本标准规定了医嘱信息交互服务消息的模板、消息架构的要求以及对消息内容的约束。
本标准适用于医嘱信息交互服务的应用。
2 规范性引用文件
下列文件中的内容通过文中的规范性引用而构成本标准必不可少的条款。其中,注日期的引用文件,
仅该日期对应的版本适用于本标准;不注日期的引用文件,其最新版本(包括所有的修改单)适用于本
标准。
GB/T 2261.1 个人基本信息分类与代码第1部分:人的性别代码
WS/T 445(所有部分) 电子病历基本数据集
WS/T 846.1 医院信息平台交互标准第1部分:总则
3 术语和定义
WS/T 846.1中界定的术语和定义均适用于本标准。
4 交互服务
4.1 医嘱信息新增服务(OrderInfoAdd)
4.1.1 角色和交易
4.1.1.1 角色交易图
医嘱信息新增服务的角色交易图如图1所示。
医嘱信息新增服务
OrderInfoAdd
医嘱信息源
医嘱信息新增
图1 医嘱信息新增服务角色交易图
4.1.1.2 角色的选择
医嘱信息新增服务的角色列表如表1所示。
表1 医嘱信息新增服务角色列表
角色交易选择
医嘱信息源医嘱信息新增必选项(R)
医嘱信息新增服务医嘱信息新增必选项(R)
4.1.1.3 交易流程
WS/T 846.8-2024
2
医嘱信息新增服务的交易流程图如图2所示。
图2 医嘱信息新增服务交易流程图
医嘱信息新增服务的交易流程描述:
——医嘱信息源向医嘱信息新增服务提交请求消息;
——医嘱信息新增服务校验数据并进行存储,新增成功时返回成功响应消息;
——医嘱信息新增服务新增失败时返回异常响应消息。
4.1.2 接口规范模型
4.1.2.1 请求消息模型
医嘱信息新增服务的请求消息模型如表2所示。
表2 医嘱信息新增服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signatureCo
de/@code 0..1 O 签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/
@value 0..1 O 医嘱审核日期时间DE06.00.504.00
substanceAdministrationRequest/ verifier/
signatureText/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig 0..1 O 医嘱审核医师工号字符串,最大长度
WS/T 846.8-2024
3
节点基数可选项节点说明
对应数据元标识符/
格式要求
nedEntity/id/item/@extension 为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱开始日期时间DE06.00.220.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@ codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@ codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码DE06.00.133.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/ 0..1 O 药物使用总剂量DE06.00.135.00
WS/T 846.8-2024
4
节点基数可选项节点说明
对应数据元标识符/
格式要求
item/numerator/@value
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio 0..1 O 固定值—
WS/T 846.8-2024
5
节点基数可选项节点说明
对应数据元标识符/
格式要求
n/observation/value/@codeSystem "2.16.156.10011.2.3.2.58"
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e
xtension
0..1 O 患者身份证件号码DE02.01.030.02
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item
/part/@value
1..1 R 患者姓名DE02.01.039.01
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O
固定值"生理性别代码表
(GB/T 2261.1)"
—
WS/T 846.8-2024
6
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码DE02.01.040.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码DE08.10.025.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/name/item/part/@value
0..1 O 患者科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
WS/T 846.8-2024
7
4.1.2.2 响应消息模型(成功)
医嘱信息新增服务的响应消息模型(成功)如表3所示。
表3 医嘱信息新增服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.1.2.3 响应消息模型(异常)
医嘱信息新增服务的响应消息模型(异常)如表4所示。
表4 医嘱信息新增服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.2 医嘱信息更新服务(OrderInfoUpdate)
4.2.1 角色和交易
4.2.1.1 角色交易图
医嘱信息更新服务的角色交易图如图3所示。
医嘱信息更新服务
OrderInfoUpdate
医嘱信息源
医嘱信息更新
图3 医嘱信息更新服务角色交易图
4.2.1.2 角色的选择
WS/T 846.8-2024
8
医嘱信息更新服务的角色列表如表5所示。
表5 医嘱信息更新服务角色列表
角色交易选择
医嘱信息源医嘱信息更新必选项(R)
医嘱信息更新服务医嘱信息更新必选项(R)
4.2.1.3 交易流程
医嘱信息更新服务的交易流程图如图4所示。
图4 医嘱信息更新服务交易流程图
医嘱信息更新服务的交易流程描述:
——医嘱信息源向医嘱信息更新服务提交请求消息;
——医嘱信息更新服务校验数据并进行存储,更新成功时返回成功响应消息;
——医嘱信息更新服务更新失败时返回异常响应消息。
4.2.2 接口规范模型
4.2.2.1 请求消息模型
医嘱信息更新服务的请求消息模型如表6所示。
表6 医嘱信息更新服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signat
ureCode/@code 0..1 O 签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码DE08.10.025.00
WS/T 846.8-2024
9
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/
@value 0..1 O 医嘱审核日期时间DE06.00.504.00
substanceAdministrationRequest/verifier/signatureTe
xt/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@extension 0..1 O 医嘱审核医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱计划开始日期时间DE06.00.220.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱计划结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.133.00
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
WS/T 846.8-2024
10
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@value
0..1 O 药物使用总剂量DE06.00.135.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
WS/T 846.8-2024
11
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.2.58" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystemName
0..1 O 固定值"医嘱类别代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e 0..1 O 患者身份证件号码DE02.01.030.02
WS/T 846.8-2024
12
节点基数可选项节点说明
对应数据元标识符/
格式要求
xtension
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item
/part/@value
1..1 R 患者姓名DE02.01.039.01
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O 固定值"生理性别代码表(GB/T
2261.1)" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码DE02.01.040.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic 0..1 O 患者科室名称DE08.10.026.00
WS/T 846.8-2024
13
节点基数可选项节点说明
对应数据元标识符/
格式要求
eProviderOrganization/name/item/part/@value
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
4.2.2.2 响应消息模型(成功)
医嘱信息更新服务的响应消息模型(成功)如表7所示。
表7 医嘱信息更新服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.2.2.3 响应消息模型(异常)
医嘱信息更新服务的响应消息模型(异常)如表8所示。
表8 医嘱信息更新服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.3 医嘱信息查询服务(OrderInfoQuery)
4.3.1 角色和交易
4.3.1.1 角色交易图
WS/T 846.8-2024
14
医嘱信息查询服务的角色交易图如图5所示。
医嘱信息查询服务
OrderInfoQuery
医嘱信息使用者
医嘱信息查询
图5 医嘱信息查询服务角色交易图
4.3.1.2 角色的选择
医嘱信息查询服务的角色列表如表9所示。
表9 医嘱信息查询服务角色列表
角色交易选择
医嘱信息使用者医嘱信息查询必选项(R)
医嘱信息查询服务医嘱信息查询必选项(R)
4.3.1.3 交易流程
医嘱信息查询服务的交易流程图如图6所示。
图6 医嘱信息查询服务交易流程图
医嘱信息查询服务的交易流程描述:
——医嘱信息使用者向医嘱信息查询服务提交医嘱信息查询请求消息;
——医嘱信息查询服务将查询结果返回给医嘱信息使用者,查询成功时返回成功响应消息;
——医嘱信息查询服务查询失败时返回异常响应消息。
4.3.2 接口规范模型
4.3.2.1 请求消息模型
医嘱信息查询服务的请求消息模型如表10所示。
表10 医嘱信息查询服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间日期时间格式,
WS/T 846.8-2024
15
节点基数可选项节点说明
对应数据元标识符/
格式要求
DT15
/controlActProcess/queryByParameter/queryByPara
meterPayload/actId/value/item/@extension 1..1 R 医嘱编号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/actId/value/item/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/queryByParameter/queryByPara
meterPayload/authorId/value/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/authorId/value/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/queryByParameter/queryByPara
meterPayload/effectiveTime/value/low/@value 0..1 O 医嘱有效期间(低值)
日期型,最大长度
为15
/controlActProcess/queryByParameter/queryByPara
meterPayload/effectiveTime/value/high/@value 0..1 O 医嘱有效期间(高值)
日期型,最大长度
为15
/controlActProcess/queryByParameter/queryByPara
meterPayload/patientId /value/item/@extension 0..1 O 患者编号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/patientId /value/item/@root 0..1 O 固定值"2.16.156.10011.2.5.1.4" —
4.3.2.2 响应消息模型(成功)
医嘱信息查询服务的响应消息模型(成功)如表11所示。
表11 医嘱信息查询服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功
字符串,最大长度
为10
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signat
ureCode/@code 0..1 O 电子签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/ 0..1 O 医嘱审核日期时间DE06.00.504.00
WS/T 846.8-2024
16
节点基数可选项节点说明
对应数据元标识符/
格式要求
@value
substanceAdministrationRequest/ verifier/
signatureText/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@extension 0..1 O 医嘱审核医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value/ 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱计划开始日期时间DE06.00.222.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱计划结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.133.00
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
WS/T 846.8-2024
17
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@value
0..1 O 药物使用总剂量DE06.00.135.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
WS/T 846.8-2024
18
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.2.58" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystemName
0..1 O 固定值"医嘱类别代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e
xtension
0..1 O 患者身份证件号码DE02.01.030.02
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item 1..1 R 患者姓名DE02.01.039.01
WS/T 846.8-2024
19
节点基数可选项节点说明
对应数据元标识符/
格式要求
/part/@value
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O
固定值"生理性别代码表
(GB/T 2261.1)"
—
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码
/controlActProcess/subject/placerGroup/componentO DE02.01.040.00
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别名称
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/name/item/part/@value
0..1 O 科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区号
字符串,最大长度
为50
WS/T 846.8-2024
20
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
/controlActProcess/queryAck/queryResponseCode/@
code 1..1 R 查询结果代码
字符串,最大长度
为50
4.3.2.3 响应消息模型(异常)
医嘱信息查询服务的响应消息模型(异常)如表12所示。
表12 医嘱信息查询服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
/controlActProcess/queryAck/queryResponseCode/@
code 1..1 R 查询结果代码
字符串,最大长度
为50
WS/T 846.8-2024
21
附录A
(资料性)
消息示例
A.1 医嘱信息新增服务
A.1.1 医嘱信息新增服务-请求消息
ITSVersion="XML_1.0" xsi:schemaLocation="https://www.chiss.org.cn
https://www.chiss.org.cn/HL7V3Message/multicacheschemas/POOR_IN200901UV.xsd">
CCS C 07
WS
中华人民共和国卫生行业标准
WS/T 846.8—2024
医院信息平台交互标准
第8 部分:医嘱信息交互服务
Hospital information platform interactive standard—
Part 8:Order information interactive services
2024 - 10 - 28 发布2025 - 04 - 01 实施
中华人民共和国国家卫生健康委员会 发布
WS/T 846.8-2024
I
前言
本标准是WS/T 846《医院信息平台交互标准》的第8部分。WS/T 846已经发布以下部分:
——第1部分:总则
——第2部分:个人信息注册、查询服务;
——第3部分:医疗卫生机构注册、查询服务;
——第4部分:医疗卫生人员注册、查询服务;
——第5部分:术语注册、查询服务;
——第6部分:文档注册、查询服务;
——第7部分:就诊信息交互服务;
——第8部分:医嘱信息交互服务;
——第9部分:申请单信息交互服务;
——第10部分:预约信息交互服务;
——第11部分:状态信息交互服务。
本标准由国家卫生健康标准委员会卫生健康信息标准专业委员会负责技术审查和技术咨询,由国家
卫生健康委统计信息中心负责协调性和格式审查,由国家卫生健康委规划发展与信息化司负责业务管
理、法规司负责统筹管理。
本标准主要起草单位:国家卫生健康委统计信息中心、重庆大学、大连大学附属中山医院、国家电
子计算机质量检验检测中心。
本标准主要起草人:董方杰、李岳峰、张翔、郑良、钟代笛、刁晓东。
WS/T 846.8-2024
1
医院信息平台交互标准第8 部分:医嘱信息交互服务
1 范围
本标准规定了医嘱信息交互服务消息的模板、消息架构的要求以及对消息内容的约束。
本标准适用于医嘱信息交互服务的应用。
2 规范性引用文件
下列文件中的内容通过文中的规范性引用而构成本标准必不可少的条款。其中,注日期的引用文件,
仅该日期对应的版本适用于本标准;不注日期的引用文件,其最新版本(包括所有的修改单)适用于本
标准。
GB/T 2261.1 个人基本信息分类与代码第1部分:人的性别代码
WS/T 445(所有部分) 电子病历基本数据集
WS/T 846.1 医院信息平台交互标准第1部分:总则
3 术语和定义
WS/T 846.1中界定的术语和定义均适用于本标准。
4 交互服务
4.1 医嘱信息新增服务(OrderInfoAdd)
4.1.1 角色和交易
4.1.1.1 角色交易图
医嘱信息新增服务的角色交易图如图1所示。
医嘱信息新增服务
OrderInfoAdd
医嘱信息源
医嘱信息新增
图1 医嘱信息新增服务角色交易图
4.1.1.2 角色的选择
医嘱信息新增服务的角色列表如表1所示。
表1 医嘱信息新增服务角色列表
角色交易选择
医嘱信息源医嘱信息新增必选项(R)
医嘱信息新增服务医嘱信息新增必选项(R)
4.1.1.3 交易流程
WS/T 846.8-2024
2
医嘱信息新增服务的交易流程图如图2所示。
图2 医嘱信息新增服务交易流程图
医嘱信息新增服务的交易流程描述:
——医嘱信息源向医嘱信息新增服务提交请求消息;
——医嘱信息新增服务校验数据并进行存储,新增成功时返回成功响应消息;
——医嘱信息新增服务新增失败时返回异常响应消息。
4.1.2 接口规范模型
4.1.2.1 请求消息模型
医嘱信息新增服务的请求消息模型如表2所示。
表2 医嘱信息新增服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signatureCo
de/@code 0..1 O 签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/
@value 0..1 O 医嘱审核日期时间DE06.00.504.00
substanceAdministrationRequest/ verifier/
signatureText/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig 0..1 O 医嘱审核医师工号字符串,最大长度
WS/T 846.8-2024
3
节点基数可选项节点说明
对应数据元标识符/
格式要求
nedEntity/id/item/@extension 为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱开始日期时间DE06.00.220.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@ codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@ codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码DE06.00.133.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/ 0..1 O 药物使用总剂量DE06.00.135.00
WS/T 846.8-2024
4
节点基数可选项节点说明
对应数据元标识符/
格式要求
item/numerator/@value
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio 0..1 O 固定值—
WS/T 846.8-2024
5
节点基数可选项节点说明
对应数据元标识符/
格式要求
n/observation/value/@codeSystem "2.16.156.10011.2.3.2.58"
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e
xtension
0..1 O 患者身份证件号码DE02.01.030.02
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item
/part/@value
1..1 R 患者姓名DE02.01.039.01
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O
固定值"生理性别代码表
(GB/T 2261.1)"
—
WS/T 846.8-2024
6
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码DE02.01.040.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码DE08.10.025.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/name/item/part/@value
0..1 O 患者科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
WS/T 846.8-2024
7
4.1.2.2 响应消息模型(成功)
医嘱信息新增服务的响应消息模型(成功)如表3所示。
表3 医嘱信息新增服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.1.2.3 响应消息模型(异常)
医嘱信息新增服务的响应消息模型(异常)如表4所示。
表4 医嘱信息新增服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.2 医嘱信息更新服务(OrderInfoUpdate)
4.2.1 角色和交易
4.2.1.1 角色交易图
医嘱信息更新服务的角色交易图如图3所示。
医嘱信息更新服务
OrderInfoUpdate
医嘱信息源
医嘱信息更新
图3 医嘱信息更新服务角色交易图
4.2.1.2 角色的选择
WS/T 846.8-2024
8
医嘱信息更新服务的角色列表如表5所示。
表5 医嘱信息更新服务角色列表
角色交易选择
医嘱信息源医嘱信息更新必选项(R)
医嘱信息更新服务医嘱信息更新必选项(R)
4.2.1.3 交易流程
医嘱信息更新服务的交易流程图如图4所示。
图4 医嘱信息更新服务交易流程图
医嘱信息更新服务的交易流程描述:
——医嘱信息源向医嘱信息更新服务提交请求消息;
——医嘱信息更新服务校验数据并进行存储,更新成功时返回成功响应消息;
——医嘱信息更新服务更新失败时返回异常响应消息。
4.2.2 接口规范模型
4.2.2.1 请求消息模型
医嘱信息更新服务的请求消息模型如表6所示。
表6 医嘱信息更新服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signat
ureCode/@code 0..1 O 签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码DE08.10.025.00
WS/T 846.8-2024
9
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/
@value 0..1 O 医嘱审核日期时间DE06.00.504.00
substanceAdministrationRequest/verifier/signatureTe
xt/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@extension 0..1 O 医嘱审核医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱计划开始日期时间DE06.00.220.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱计划结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.133.00
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
WS/T 846.8-2024
10
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@value
0..1 O 药物使用总剂量DE06.00.135.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
WS/T 846.8-2024
11
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.2.58" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystemName
0..1 O 固定值"医嘱类别代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e 0..1 O 患者身份证件号码DE02.01.030.02
WS/T 846.8-2024
12
节点基数可选项节点说明
对应数据元标识符/
格式要求
xtension
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item
/part/@value
1..1 R 患者姓名DE02.01.039.01
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O 固定值"生理性别代码表(GB/T
2261.1)" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码DE02.01.040.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic 0..1 O 患者科室名称DE08.10.026.00
WS/T 846.8-2024
13
节点基数可选项节点说明
对应数据元标识符/
格式要求
eProviderOrganization/name/item/part/@value
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
4.2.2.2 响应消息模型(成功)
医嘱信息更新服务的响应消息模型(成功)如表7所示。
表7 医嘱信息更新服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.2.2.3 响应消息模型(异常)
医嘱信息更新服务的响应消息模型(异常)如表8所示。
表8 医嘱信息更新服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
4.3 医嘱信息查询服务(OrderInfoQuery)
4.3.1 角色和交易
4.3.1.1 角色交易图
WS/T 846.8-2024
14
医嘱信息查询服务的角色交易图如图5所示。
医嘱信息查询服务
OrderInfoQuery
医嘱信息使用者
医嘱信息查询
图5 医嘱信息查询服务角色交易图
4.3.1.2 角色的选择
医嘱信息查询服务的角色列表如表9所示。
表9 医嘱信息查询服务角色列表
角色交易选择
医嘱信息使用者医嘱信息查询必选项(R)
医嘱信息查询服务医嘱信息查询必选项(R)
4.3.1.3 交易流程
医嘱信息查询服务的交易流程图如图6所示。
图6 医嘱信息查询服务交易流程图
医嘱信息查询服务的交易流程描述:
——医嘱信息使用者向医嘱信息查询服务提交医嘱信息查询请求消息;
——医嘱信息查询服务将查询结果返回给医嘱信息使用者,查询成功时返回成功响应消息;
——医嘱信息查询服务查询失败时返回异常响应消息。
4.3.2 接口规范模型
4.3.2.1 请求消息模型
医嘱信息查询服务的请求消息模型如表10所示。
表10 医嘱信息查询服务请求消息模型
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间日期时间格式,
WS/T 846.8-2024
15
节点基数可选项节点说明
对应数据元标识符/
格式要求
DT15
/controlActProcess/queryByParameter/queryByPara
meterPayload/actId/value/item/@extension 1..1 R 医嘱编号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/actId/value/item/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/queryByParameter/queryByPara
meterPayload/authorId/value/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/authorId/value/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/queryByParameter/queryByPara
meterPayload/effectiveTime/value/low/@value 0..1 O 医嘱有效期间(低值)
日期型,最大长度
为15
/controlActProcess/queryByParameter/queryByPara
meterPayload/effectiveTime/value/high/@value 0..1 O 医嘱有效期间(高值)
日期型,最大长度
为15
/controlActProcess/queryByParameter/queryByPara
meterPayload/patientId /value/item/@extension 0..1 O 患者编号
字符串,最大长度
为50
/controlActProcess/queryByParameter/queryByPara
meterPayload/patientId /value/item/@root 0..1 O 固定值"2.16.156.10011.2.5.1.4" —
4.3.2.2 响应消息模型(成功)
医嘱信息查询服务的响应消息模型(成功)如表11所示。
表11 医嘱信息查询服务响应消息模型(成功)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AA"表示成功
字符串,最大长度
为10
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/author/time/
@value 1..1 R 医嘱开立日期时间DE08.50.033.00
/controlActProcess/subject/placerGroup/author/signat
ureCode/@code 0..1 O 电子签名编码,固定值"S" —
/controlActProcess/subject/placerGroup/author/signat
ureText/@value 0..1 O 医嘱开立医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@extension 0..1 O 医嘱开立医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/assignedPerson/name/item/part/@value 0..1 O 医嘱开立医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@extension 0..1 O 医嘱开立科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/id/item/@root 0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/author/assign
edEntity/representedOrganization/name/item/part/@v
alue
0..1 O 医嘱开立科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/verifier/time/ 0..1 O 医嘱审核日期时间DE06.00.504.00
WS/T 846.8-2024
16
节点基数可选项节点说明
对应数据元标识符/
格式要求
@value
substanceAdministrationRequest/ verifier/
signatureText/@value 0..1 O 医嘱审核医师签名DE02.01.039.00
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@extension 0..1 O 医嘱审核医师工号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/id/item/@root 0..1 O 固定值"2.16.156.10011.1.4" —
/controlActProcess/subject/placerGroup/verifier/assig
nedEntity/assignedPerson/name/item/part/@value/ 0..1 O 医嘱审核医师姓名DE02.01.039.00
/controlActProcess/subject/placerGroup/component2 1..* R 医嘱信息根节点—
/controlActProcess/subject/placerGroup/component2/
sequenceNumber/@value 0..1 O 医嘱序号
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@extension 1..1 R 医嘱编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/id/@root 1..1 R 固定值"2.16.156.10011.1.28" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem 0..1 O 固定值
"2.16.156.10011.2.3.1.268" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@codeSystem
Name
0..1 O 固定值"医嘱项目类型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/code/@code 0..1 O 医嘱项目类型代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.289.00
substanceAdministrationRequest/code/displayName/
@value
0..1 O 医嘱项目类型名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/text/@value 0..1 O 医嘱项目内容DE06.00.288.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeLow
0..1 O 医嘱计划开始日期时间DE06.00.222.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/@
validTimeHigh
0..1 O 医嘱计划结束日期时间DE06.00.219.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystem
0..1 O 固定值
"2.16.156.10011.2.5.1.13" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@codeSystemName
0..1 O 固定值"药物使用频次代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/effectiveTime/code/
@code
0..1 O 药物使用频次代码
/controlActProcess/subject/placerGroup/component2/ DE06.00.133.00
substanceAdministrationRequest/effectiveTime/code/
displayName/@value
0..1 O 药物使用频次名称
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.3.1.158" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@codeS
ystemName
0..1 O 固定值"用药途径代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/@code 0..1 O 药物使用途径代码DE06.00.134.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/routeCode/displayN
ame/@value
0..1 O 药物使用途径描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@val
ue
0..1 O 药物使用次剂量DE08.50.023.00
WS/T 846.8-2024
17
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseQuantity/@unit 0..1 O 药物使用剂量单位DE08.50.024.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@value
0..1 O 药物使用总剂量DE06.00.135.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/numerator/@unit
0..1 O 药物使用总剂量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/doseCheckQuantity/
item/denominator/@value
0..1 O 药物使用总剂量天数
数值型,最大长度
为4
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.1.211" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@codeSystemName
0..1 O 固定值"药物剂型代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/@code
0..1 O 药品剂型代码DE08.50.011.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/administrationUnit
Code/displayName/@value
0..1 O 药品剂型描述
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@codeS
ystem
0..1 O 固定值
"2.16.156.10011.2.5.1.14" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/code/@code
0..1 O 药物编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/name/item/par
t/@value
0..1 O 药物名称DE08.50.022.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@value
0..1 O 药物规格DE08.50.043.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/manufacturedProduct/asContent/con
tainerPackagedProduct/capacityQuantity/@unit
0..1 O 药物规格单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/@code
0..1 O 药物医保类别编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/consumable2/manuf
acturedProduct1/subjectOf3/policy/code/displayNam
e/@value
0..1 O 药物医保类别名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@extension
0..1 O 执行科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/location/serviceDeli
veryLocation/location/name/item/part/@value
0..1 O 执行科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/occurrenceOf/paren
tRequestReference/id/@extension
0..1 O 父医嘱编码
字符串,最大长度
为50
WS/T 846.8-2024
18
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@code
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystem
0..1 O 固定值
"2.16.156.10011.2.3.2.58" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/@codeSystemName
0..1 O 固定值"医嘱类别代码表" —
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/pertinentInformatio
n/observation/value/displayName/@value
0..1 O 医嘱类别代码DE06.00.286.00
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@value
0..1 O 领药量
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/component2/supply
Request/quantity/@unit
0..1 O 领药量单位
字符串,最大长度
为10
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/text/@value
0..1 O 医嘱备注信息
字符串,最大长度
为200
/controlActProcess/subject/placerGroup/component2/
substanceAdministrationRequest/subjectOf6/annotati
on/statusCode/@code
0..1 O 医嘱备注信息状态
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊次数
数值型,最大长度
为3
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.8" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@extension 1..1 R 就诊流水号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.9" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@code 1..1 R 患者类型代码DE02.01.060.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/@codeSystem 1..1 R 固定值
"2.16.156.10011.2.3.1.271" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/code/displayName/@value 1..1 R 患者类型名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 1..1 R 患者编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 1..1 R 固定值"2.16.156.10011.2.5.1.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 门(急)诊号DE01.00.010.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.11" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@extension 0..1 O 住院号DE01.00.014.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/id/item/@root 0..1 O 固定值"2.16.156.10011.1.12" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/telecom/item/@value 0..1 O 患者电话号码DE02.01.010.05
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@e
xtension
0..1 O 患者身份证件号码DE02.01.030.02
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/id/item/@r
oot
0..1 O 固定值"2.16.156.10011.1.3" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/name/item 1..1 R 患者姓名DE02.01.039.01
WS/T 846.8-2024
19
节点基数可选项节点说明
对应数据元标识符/
格式要求
/part/@value
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystem
0..1 O 固定值"2.16.156.10011.2.3.3.4" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@codeSystemName
0..1 O
固定值"生理性别代码表
(GB/T 2261.1)"
—
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/@code
0..1 O 患者性别代码
/controlActProcess/subject/placerGroup/componentO DE02.01.040.00
f1/encounter/subject/patient/patientPerson/administra
tiveGenderCode/displayName/@value
0..1 O 患者性别名称
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/birthTime/
@value
0..1 O 患者出生日期DE02.01.005.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@extension
0..1 O 健康档案编号DE01.00.009.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item[@root="2.16.156.10011.1.2"]/@root
0..1 O 固定值"2.16.156.10011.1.2" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@extension
0..1 O 居民健康卡号DE01.00.021.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/subject/patient/patientPerson/asOtherID
s/id/item/@root
0..1 O 固定值"2.16.156.10011.1.19" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@extension
0..1 O 病床号DE01.00.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/id/item/@root
0..1 O 固定值"2.16.156.10011.1.22" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/name/item/part/@value
0..1 O 病床号名称
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@extensio
n
0..1 O 病房号
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/id/item/@root
0..1 O 固定值"2.16.156.10011.1.21" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/locati
on/asLocatedEntityPartOf/location/name/item/part/@
value
0..1 O 病房号名称DE01.00.019.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@extension
0..1 O 患者科室编码
字符串,最大长度
为50
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.26" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/name/item/part/@value
0..1 O 科室名称DE08.10.026.00
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@extension
0..1 O 病区号
字符串,最大长度
为50
WS/T 846.8-2024
20
节点基数可选项节点说明
对应数据元标识符/
格式要求
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/id/item/@root
0..1 O 固定值"2.16.156.10011.1.27" —
/controlActProcess/subject/placerGroup/componentO
f1/encounter/location/serviceDeliveryLocation/servic
eProviderOrganization/asOrganizationPartOf/wholeO
rganization/name/item/part/@value
0..1 O 病区名称DE08.10.054.00
/controlActProcess/queryAck/queryResponseCode/@
code 1..1 R 查询结果代码
字符串,最大长度
为50
4.3.2.3 响应消息模型(异常)
医嘱信息查询服务的响应消息模型(异常)如表12所示。
表12 医嘱信息查询服务响应消息模型(异常)
节点基数可选项节点说明
对应数据元标识符/
格式要求
/id/@extension 1..1 R 消息流水号
字符串,最大长度
为50
/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/creationTime/@value 1..1 R 消息创建时间
日期时间格式,
DT15
/acknowledgement/@typeCode 1..1 R 处理结果,固定值"AE"表示失败—
/acknowledgement/targetMessage/id/@extension 1..1 R 请求消息流水号
字符串,最大长度
为50
/acknowledgement/targetMessage/id/@root 1..1 R 固定值"2.16.156.10011.2.5.1.1" —
/acknowledgement/acknowledgementDetail/text/@va
lue 1..1 R 处理结果说明
字符串,最大长度
为200
/controlActProcess/queryAck/queryResponseCode/@
code 1..1 R 查询结果代码
字符串,最大长度
为50
WS/T 846.8-2024
21
附录A
(资料性)
消息示例
A.1 医嘱信息新增服务
A.1.1 医嘱信息新增服务-请求消息
ITSVersion="XML_1.0" xsi:schemaLocation="https://www.chiss.org.cn
https://www.chiss.org.cn/HL7V3Message/multicacheschemas/POOR_IN200901UV.xsd">
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