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台湾TMT电子病历架构

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版本：V1.01
行政院衛生署委辦計畫
台灣醫學資訊學會製
2005.7.5
目錄
第一章 TMT 電子病歷架構圖.............................................................................................................5
TMT 電子病歷架構圖...................................................................................................................6
第二章門?....................................................................................................................................7
病歷首頁單.................................................................................................................................8
西醫門詥?................................................................................................................................9
牙醫門詥?..............................................................................................................................10
中醫門詥?.............................................................................................................................. 11
中醫傷科針灸單........................................................................................................................12
第三章急?..................................................................................................................................13
急曰举Y料單........................................................................................................................14
急詸z傷分類單........................................................................................................................15
急匀朐河?#63807;單........................................................................................................................16
急葬t囑單...............................................................................................................................17
第四章住院...................................................................................................................................18
住院基本資料單........................................................................................................................19
住院入院記錄單........................................................................................................................20
出院病摘單...............................................................................................................................21
病程紀錄單...............................................................................................................................22
住院醫囑單...............................................................................................................................23
會陨暾垎?..............................................................................................................................24
麻醉紀錄單...............................................................................................................................25
手術記錄單...............................................................................................................................26
中醫住院單...............................................................................................................................27
第五章護理...................................................................................................................................28
急宰o理處置單........................................................................................................................29
入院護理評估單........................................................................................................................30
生命徵象測量記錄單................................................................................................................31
護理記錄單...............................................................................................................................32
護理詳鄦?..............................................................................................................................33
護理計畫單...............................................................................................................................34
第六章計畫申請............................................................................................................................35
處方箋.......................................................................................................................................36
實驗室檢查申請單....................................................................................................................37
醫學影像檢查申請單................................................................................................................38
核子醫學檢查申請單................................................................................................................39
超音波檢查申請單....................................................................................................................40
電腦斷層掃描檢查申請單........................................................................................................41
心電圖檢查申請單....................................................................................................................42
腦波檢查申請單........................................................................................................................43
病理檢查申請單........................................................................................................................44
第七章報告...................................................................................................................................45
3
藥師調劑單...............................................................................................................................46
實驗室檢查報告單....................................................................................................................47
放射線檢查報告單....................................................................................................................48
核子醫學檢查報告單................................................................................................................49
超音波檢查報告單....................................................................................................................50
電腦斷層掃描檢查報告單........................................................................................................51
心電圖檢查報告單....................................................................................................................52
腦波檢查報告單........................................................................................................................53
病理檢查報告單........................................................................................................................54
會詧蟾鎲?..............................................................................................................................55
第八章其他...................................................................................................................................56
營養諮詢單...............................................................................................................................57
衛教單.......................................................................................................................................58
第九章同意書...............................................................................................................................59
手術同意書...............................................................................................................................60
麻醉同意書...............................................................................................................................61
通用同意書...............................................................................................................................62
第十章模組...................................................................................................................................63
醫療機構資料模組....................................................................................................................64
醫療機構簽章模組....................................................................................................................65
各類病史模組............................................................................................................................66
常見過去病史模組....................................................................................................................67
過敏史模組...............................................................................................................................68
個人史模組...............................................................................................................................69
家族史模組...............................................................................................................................70
產科史模組...............................................................................................................................71
月經史模組...............................................................................................................................72
其他病史模組............................................................................................................................73
手術及入出院索引模組............................................................................................................74
病人基本資料模組....................................................................................................................75
病人基本資料摘要模組............................................................................................................76
中醫傷科針灸計畫模組............................................................................................................77
中醫客觀模組............................................................................................................................78
急曰举Y料摘要模組............................................................................................................79
急宰o理處置模組....................................................................................................................80
護理監測評估模組....................................................................................................................81
護理醫療處置模組....................................................................................................................82
輸血記錄模組............................................................................................................................83
住院護理模組............................................................................................................................84
護理其他記錄模組....................................................................................................................85
院內動向模組............................................................................................................................86
出院時情況模組........................................................................................................................87
醫囑模組...................................................................................................................................88
4
手術模組...................................................................................................................................89
主觀模組...................................................................................................................................90
客觀模組...................................................................................................................................91
理學檢查模組............................................................................................................................92
系統評估模組............................................................................................................................93
評估模組...................................................................................................................................94
疾病詳嗄＝M............................................................................................................................95
處置申請模組............................................................................................................................96
治療程序模組............................................................................................................................97
檢查項目模組............................................................................................................................98
開藥模組...................................................................................................................................99
報告模組.................................................................................................................................100
給藥模組.................................................................................................................................101
投保身份別模組......................................................................................................................102
急缘皆耗＝M..........................................................................................................................103
急钥苿e模組..........................................................................................................................104
西醫科別模組..........................................................................................................................105
主訴模組.................................................................................................................................106
生命徵象模組..........................................................................................................................107
到院方式模組..........................................................................................................................108
詳?出入院史模組................................................................................................................109
表單資料模組.......................................................................................................................... 110
簽章模組................................................................................................................................. 111
醫師群組簽章模組.................................................................................................................. 112
交換模組................................................................................................................................. 113
溝通模組................................................................................................................................. 114
關聯模組................................................................................................................................. 115
價值模組................................................................................................................................. 116
選擇模組................................................................................................................................. 117
移動模組................................................................................................................................. 118
感受模組................................................................................................................................. 119
知識模組.................................................................................................................................120
感覺模組.................................................................................................................................121
法定通報項目模組..................................................................................................................122
5
第一章 TMT 電子病歷架

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