Nghien Cuu Chuan HL7

I HC QUC GIA THNH PH H CH MINH TRNG I HC BCH KHOA KHOA KHOA HC NG DNG-----------------------------

LUN VN TT NGHIP

NGHIN CU CHUN HL7 DNG TRAO I D LIU IN T TRONG Y KHOA V XY DNG CHNG TRNH C BN TIN HL7

GVHD: TS. HUNH QUANG LINH SVTH: V THANH HONGEmail : [email protected]

Tp. H Ch Minh, Thng 01 Nm 2007i

Li CM N

LI CM N hon thnh tt lun vn ny, ngoi s n lc ht mnh ca bn thn, cn l nh s gip t nhng ngi khc. Ti xin chn thnh gi li cm n n: Thy, TS. Hunh Quang Linh, ngi tn tnh hng dn ti xuyn sut qu trnh lm lun vn Cc Thy C trong khoa Khoa Hc ng Dng cho em nhiu kin thc b ch Cc bn trong lp Vt L K Thut Y sinh K02 thn thng, cc anh em d mn trong cng phng tr ng vin, c v Xin cm n Ba, Me h tr, to iu kin ti a cho con. Cm n anh Lim nhit tnh gip em, v b t lun c v cho anh Cm n em, Jenny, ngi yu du ca anh, lun bn anh, ng vin, h tr trong nhng lc anh kh khn nht Xin c t lng bit n n mi ngi gip ti trong sut qu trnh hon thnh lun vn. Xin tri n,

V THANH HONG

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TM TT LUN VNLun vn tp trung nghin cu v ni dung tiu chun nh dng bn tin HL7 phin bn 2.3.1. y l mt chun v d liu dng vn bn thng tin y t c ng dng kh rng ri v c trin vng pht trin thnh chun thng nht trong mng thng tin y t th gii. Ni dung ca tiu chun rt rng (trn 1200 trang ton text), y v chi tit, hu ht mi vn lin quan n vn bn trong thng tin y t u c th s dng chun ny. Do gii hn v thi gian, lun vn c gii hn nghin cu chun HL7 v cu trc bn tin Nhp vin ca bnh nhn, trn c s , mt chng trnh phn mm c chc nng to v dch mt bn tin tun theo chun HL7 (da theo s kin bnh nhn nhp vin) c thit k. Phn mm ny c xy dng c th to, c v tm kim danh sch bnh nhn theo chun HL7 v c th ng dng th nghim trong cng tc qun l u vo bnh nhn ti cc c s y t, to nn tng pht trin phn mm tng qut qun l bnh vin theo chun HL7 trong h thng thng tin y t, c bit trong ng dng y t t xa.

iii

www.bme.vn

MC LCLI CM N..................................................................................................... ii TM TT LUN VN.................................................................................... iii MC LC.......................................................................................................... iv CHNG 1: GII THIU 1.1. M u ...................................................................................................... 1 1.2. Mc tiu v nhim v ca lun vn .......................................................... 2 CHNG 2: TNG QUAN 2.1. LCH S CHUN THNG TIN Y T HL7 ........................................... 3 2.2. NGUYN TC M HA TRONG HL7................................................. 6 2.2.1. Nguyn tc ......................................................................................... 6 2.2.2. V d v m ha v gii m mt bn tin HL7.................................... 6 2.3. CC KHI NIM C S TRONG HL7 ................................................ 7 2.3.1. S kin kch khi (trigger event) ........................................................... 7 2.3.2. Mi trng truyn thng...................................................................... 11 2.3.3. Bn tin .................................................................................................. 13 2.3.4. on ..................................................................................................... 14 2.3.5. Trng.................................................................................................. 14 2.3.6. K hiu phn nh bn tin (message delimiter) ................................... 18 2.3.7. Loi d liu .......................................................................................... 20 2.3.8. S dng cc trnh t thot ra trong trng vn bn ............................. 27 2.3.9. Cc quy lut kin trc d liu .............................................................. 30 2.3.10. Cu to mt bn tin qun tr bnh nhn ............................................. 32 2.4. CU TRC BN TIN NHP VIN ..................................................... 33 Bn tin ng k bnh nhn ADT/ACK (s kin A04).................................... 33 2.4.1. on mo u bn tin (MSH Message Header Segment)................. 34 2.4.2. on loi s kin (Event type segment EVN) ................................... 40 2.4.3. on xc nhn bnh nhn (Patient Identification segment PID) ..... 42 2.4.4. on thn nhn bnh nhn (Next of kin / associated parties segment NK1) ............................................................................................................... 51 2.4.5. on thng tin nhp vin (Patient Visit segment PV1) .................... 58 2.4.6. on thng tin chn on (Diagnosis segment DG1) ...................... 63 2.4.7. on thng tin bo him (Insurance segment IN1).......................... 67 CHNG 3: PHN THC HNH: CHNG TRNH MessageHL7 v1.0.1 3.1. Gii thiu chng trnh C V TO BN TIN HL7 .................... 70 3.2. Yu cu h thng..................................................................................... 71 3.3. S dng chng trnh.............................................................................. 71 3.4. Tr gip chng trnh ............................................................................. 74 3.5. Bn lun v chng trnh ........................................................................ 75 CHNG 4: KT LUN V HNG PHT TRINU

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4.1. Kt lun ................................................................................................... 77 4.2. Kh nng v hng pht trin ................................................................. 78 TI LIU THAM KHO ............................................................................... 79 PH LC PH LC A BNG HL7 V NGI DNG NH NGHA..................... 80 PH LC B LOI BN TIN ........................................................................ 98 PH LC C CC ON CA BN TIN ................................................. 101 PH LC D M NGUN CHNG TRNH ........................................... 105

v

CC T VIT TT VD V d

LVTN: NGHIN CU CHUN HL7 V XY DNG CT C BN TIN HL7

TRNG H BK TP.HCM 2007

CHNG 1:1.1. M u

GII THIU

Trong h thng thng tin y t, c bit l h thng thng tin bnh vin, vic lu tr nhng thng tin v bnh nhn t khi nhp vin n khi xut vin, hay l nhp vin li nhiu ln; nhng thng tin qun l hot ng trong bnh vin thng xuyn xy ra vi dung lng lu tr ln. Vic lu tr bng s sch xut hin nhng bt cp nh lng thng tin lu tr qu ln, vic tm kim kh khn, c bit l vic chia s thng tin gia cc khoa trong bnh vin hoc gia cc bnh vin vi nhau l hu nh cha thc hin c. Chnh v vy, cc bnh vin chuyn dn sang vic thu thp v lu tr thng tin bng my tnh. Tuy nhin, vic nh dng cho nhng thng tin in t ny c nhiu khc nhau gia cc bnh vin nn qu trnh chia s thng tin gp kh khn. Do , nm 1987 mt y ban gm nhng ngi s dng, nhng nh cung cp v nhng nh t vn trong lnh vc ny ng u l gio s Sam Schultz ti Bnh vin trng i hc Pennsylvania M thng nht v a ra mt chun chung cho khun dng d liu dng vn bn gi l HL7 thun tin cho vic chia s thng tin dng vn bn ny. Theo , mt lot cc quy tc m ha v gii m dng d liu vn bn c nh ngha. Vic ng dng chun d liu ny em li nhiu li ch trong cc h thng thng tin y t, c bit l lnh vc y t t xa. Vit Nam, vic ng dng cng ngh thng tin trong qun l bnh vin ang tng bc pht trin, iu ny gip truy cp thng tin nhanh, h tr cng tc chn on, thng k v nghin cu khoa hc ca cc chuyn khoa, gim thiu ti liu lu tr hng nm cho h thng bnh vin. Tuy nhin vn cha c mt chun thng nht chung no dng cho trao i d liu vn bn gia cc khoa, cc bnh vin. Trong xu th hi nhp quc t nh hin nay,

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GVHD: TS. HUNH QUANG LINH



c bit nc ta va gia nhp WTO, i hi cn c nhng h thng thng tin y t chun ha c th nng cao kh nng chm sc sc khe cho ngi dn, ha nhp cng vi cc h thng thng tin y t tin tin ca nhng nc pht trin. Do vy, mc tiu v nhim v ca lun vn c ra l:

1.2. Mc tiu v nhim v ca lun vnMc tiu c ra ca lun vn l kho st cng nng v cu trc ca tiu chun nh dng bn tin thng tin y t HL7 (phin bn 2.3.1), trn c s thit k mt chng trnh phn mm c chc nng qun l h s bnh nhn theo chun HL7 nhm th nghim kh nng ng dng trong cng tc qun l bnh vin hoc c s y t. Do ni dung ca tiu chun rng (trn 1200 trang ton text) v nhiu chi tit phc hp, t thng tin vn bn v l lch bnh nhn cho n nhng lin kt qun l hnh nh trong chn on v iu tr, lin kt vi cc c s d liu v ti chnh bo him v.v, lun vn ch gii hn nghin cu chun HL7 v cu trc bn tin Nhp vin ca bnh nhn. Cho nn, cc nhim v chnh ca lun vn c ra nh sau: Kho st tng quan v chun nh dng bn tin thng tin y t HL7 v s pht trin ng dng trong mng thng tin y t. Kho st cu trc d liu v chun nh dng bn tin thng tin y t HL7. Thit k th nghim phn mm to, c v tm kim danh sch bnh nhn theo chun HL7 v xem xt kh nng ng dng th nghim trong cng tc qun l u vo bnh nhn cc c s y t.

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CHNG 2:

TNG QUAN

2.1. Lch s chun thng tin y t HL7Tng t nh ngi ta cc nc khc nhau, c ngn ng bn a hon ton khc nhau ch c th giao tip c vi nhau nu h c th ni mt ngn ng chung, cc ng dng my tnh ch c th chia s thng tin nu chng giao tip vi cng mt ti nguyn chung. i vi ngi ta hay my tnh c th chia s d liu vi nhau, phi c: a) cc chc nng c th giao tip vt l, VD nh ni v nghe, gi v nhn ti liu, tp tin d liu, chia s d liu v thng tin. (iu ny c gi l "functional interoperability" (thao tc gia cc phn chc nng)). b) Ni mt ngn ng chung (theo cc thut ng v danh t, ng t, cu trc ng php) v chia s cng t vng m cho php chng hiu cc iu kin v cc qu trnh x l y khoa phc tp. (y c gi l "semantic interoperability" (thao tc gia cc phn ng ngha)). Mt nhm cc nh s dng h thng my tnh y t (nhng ngi sau thit lp t chc Health Level 7) vo nm 1987 bt u pht trin ti nguyn HL7 to ra ngn ng chung m cho php cc ng dng y t chia s d liu lm sng vi nhau. Theo thi gian ti nguyn hot ng trung gian HL7 tr thnh chun c cng nhn cp quc gia, quc t v ton cu. HL7 l ch vit tt ca tiu chun Health Level Seven (HL7), tiu chun ny nh dng vn bn dng trao i d liu in t trong tt c cc mi trng y t. y ban thnh lp nn chun HL7 c gi l HL7 Working Group. HL7 khng ch ph bin trong cc tiu bang nc M, m n lan rng ra nhiu nc khc nh c, Nht Bn, c, H Lan, New Zealand, v

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Canada. Ti cc nc ny, nn y hc v chm sc sc khe rt pht trin, ngi ta chp nhn s dng tiu chun HL7 nh l mt tiu chun duy nht trong trao i thng tin dng vn bn trong y t. Sau phin bn 2.2, HL7 cho xut bn phin bn 2.3 vo thng 12 nm 1994. Phin bn 2.3 l kt qu ca hn hai nm lm vic v hng ngn gi ca cc thnh vin hot ng HL7 t sau khi xut bn phin bn 2.2. Cc thnh tu chnh ca n bao gm vic duy tr c s tng thch vi phin bn 2.2, sa li v m rng tiu chun. HL7 c thit k ph hp vi cc i hi ca tiu chun ANSI (American National Standards Institute - Vin Tiu chun Quc gia Hoa k), cc t chc tiu chun v bn tin trong cng ngh my tnh lnh vc y t (ASTM - American Society for Testing Materials). HL7 ang tham gia vo y ban tiu chun thng tin y t ca ANSI (ANSIs Healthcare Informatics Standards Board - HISB). Thng 6 nm 1994, HL7 tr thnh T chc Pht trin Tiu chun ANSI chnh thc (ANSI Accredited Standards Developing Organization). Phin bn HL7 2.2 c ANSI cng nhn chnh thc nm 1996 v v2.3 c ANSI cp giy chng nhn thng 5 nm 1997. Phin bn 2.3.1 ca HL7 c ANSI cng nhn v l phin bn 2.3 c cng b rng ri. Nm 2006, HL7 cng b chnh thc xut bn phin bn HL7 v3.0. y l mt phin bn mi ca HL7 c cp nht thm nhiu phn, nh b sung phn Kin trc Ti liu Lm sng (Clinical Documents Architecture), M hnh Thng tin Tham kho (Reference Information Model - RIM) dng trong h thng thng tin y t bao gm: c im Loi d liu, nh dng d liu XML, cc T kha iu khin. Tuy nhin, hin ti chun HL7 v2.3.1 vn ang thnh hnh v ph bin nhiu nht trn th gii. Trong tng lai khng xa, ngi ta cng s dn chuyn sang chun HL7 v3.0.

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"Level Seven" ni n cp cao nht ca m hnh giao tip thng tin ca T chc Tiu chun Quc t (ISO International Standards Organization) dnh cho S kt ni trung gian ca cc h thng m (OSI Open System Interconnection), l cp ng dng. Cp ng dng nh ngha d liu c trao i, thi gian trao i v s lin lc ca cc li xy ra cho ng dng. Cp 7 h tr cc chc nng nh kim tra an ninh, nh danh tham gia, kim tra c sn, trao i vt l v quan trng nht l cu trc trao i d liu. [2]

Function

Communication

7 Application 6 Presentation 5 Session 4 Transport 3 Network 2 Data Link 1 Physical

HL7

7 Layer ISO Communication ModelThng tin thm v m hnh 7 lp ca ISO tham kho ti: http://Webopedia.internet.com/quick_ref/OSI_Layers.asp

Ni dung ca chun HL7 bao gm: a) cu trc tng th ca tt c giao din bao gm giao din truy vn chung b) qun tr bnh nhn (nhp vin, ra vin, chuyn tuyn v ng k) c) danh mc ch nh d) h thng tnh vin ph e) d liu theo di lm sng f) mt giao din tng qut cho vic ng b ha cc tp tin tham kho chung (tp tin ch) g) qun tr thng tin y khoa h) danh mc bnh nhn, danh mc ti nguyn

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i) cc bn tin tham kho ca bnh nhn dng cho hi chn gia 2 vin khc nhau j) cc bn tin chm sc bnh nhn h tr cho vic thng tin v cc chng bnh nan y, v cung cp chc nng cch thc thc thi lm sng trong h thng thng tin vi tnh. [3]

2.2. Nguyn tc m ha trong HL72.2.1. Nguyn tc

Khun dng bn tin quy nh theo nguyn tc m ha ca HL7 gm cc trng d liu, cc trng ny c di thay i v c ngn cch bi mt k t ngn cch trng. Cc nguyn tc m t cch m ha ca cc kiu d liu trong mt trng c quy nh ring. Cc trng d liu c kt hp li thnh cc nhm logic c gi l cc on. Cc on c ngn cch bi cc k t phn on. Mi on bt u vi mt gi tr ch 3 k t, gi tr ny c nhn dng trong mt bn tin. Cc on c th c nh ngha nh yu cu hoc ty chn v c th cho php c lp li. Cc trng d liu ring c tm thy trong bn tin bi v tr ca chng trong cc on kt hp. Tt c d liu c biu din nh cc k t hin th t mt k t chn. B k t hin th m ASCII (American Standard Code for Information Interchange) l b k t mc nh tr khi c s thay i trong on tiu MSH (Message Header Segment). K t ngn cch trng phi c chn t s thit lp k t hin th m ASCII. Tt c du ngn cch c bit khc v cc k t c bit cng l cc k t hin th, ngoi tr k t phn on l k t m ASCII Carriage Return (k t xung dng). [2]2.2.2. V d v m ha v gii m mt bn tin HL7

hiu hn v cu trc ca mt bn tin HL7, chng ta nghin cu mt bn tin HL7 in hnh nh vic 1 bnh nhn nhp vin s bao gm cc on thng tin chnh sau:

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1. on mo u bn tin:MSH||STORE|MISSION|MINE|LAUREL|199801181007|security|ADT|MSG0 0201|||

2. on loi s kin:EVN|01|199801181005||

3. on xc nhn bnh nhn:PID|||PATID1234567||Doe^John^B^II||19470701|M||C|371 MAIN AVE^SAN FRANCISCO^CA^94122-0619||45-681-2888||||||||

4. on thn nhn bnh nhn:NK1||Doe^Linda^E||wife|

5. on thng tin nhp vin:PV1|1|I|100^345^01||||00135^SMITH^WILLIAM^K|||SUR|ADM|

Trn y l ton b phn thng tin c m ha theo tiu chun HL7. Gii m bn tin ny, chng ta s ln lt gii m tng on trong bn tin, sau kt hp li ta thu c nhng thng tin sau:Bnh nhn John B. Doe, II, c m bnh nhn l 1234567, nam gii, da trng, sinh ngy 1 thng 7 nm 1947, sng ti 371 Avenue-Sanfrancisco, nhp vin ngy 18 thng 1 nm 1998 hi 10 gi 05 pht sng, c bc s William K.Smith xt nghim v iu tr. Bnh nhn c ch nh nm vin ti ging s 01, phng 345, t chm sc 100. Phn thn nhn c v l Linda E.Doe, bn tin c gi t Mission ti Mine sau khi bnh nhn nhp vin 2 pht.

Du | dng phn cch gia cc trng d liu, nu khng c trng d liu n c coi nh l trng trng. [1]

2.3. Cc khi nim c s trong cu trc HL7 [2]2.3.1. S kin kch khi (trigger event)

HL7 gi nh rng mt s kin trong th gii thc ca chm sc sc khe to ra nhu cu cho d liu truyn gia cc h thng. S kin th gii

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thc c gi l s kin kch khi (trigger event). VD mt bnh nhn c nhp vin (l mt trigger event) c th gy ra nhu cu cho d liu v bnh nhn c gi n mt s h thng khc. Trigger event c th l mt s theo di (VD kt qu xt nghim) cho mt bnh nhn to ra mt nhu cu cho s theo di c gi ti mt s h thng khc. Khi s truyn tin c khi to bi h thng ng dng m gii quyt vi trigger event , phin giao dch c tn gi theo thut ng l unsolicited update (s cp nht t gi i).Ch : khng c gi thit no c lm v thit k hoc kin trc ca h thngng dng to ra unsolicited update. Phm vi ca HL7 c gii hn bng c im ca cc bn tin gia cc h thng ng dng v s kin kch khi chng.

HL7 cho php s dng trigger event vi cp khc nhau ca d liu c tnh cht ht (data granularity) v cc mi quan h gia chng. VD, hu ht s kin kch khi Qun tr bnh nhn (Patient Administration ADT) lin quan n mt i tng n (nh l mt s kin nhn bnh nhn, m to ra mt bn tin cha d liu v mt bnh nhn n hoc/v mt ti khon n). Cc s kin kch khi ADT khc c lin quan vi mi quan h gia hn mt i tng (VD s kin hp bnh nhn ch nh hoc hp ti khon). Vi s kin kch khi ADT gn lin vi mt tp hp i tng m khng c mi quan h trung gian ln (VD mt truy vn a phng c p ng cha d liu v mt tp hp bnh nhn ni tr ngi m ch lin quan tm thi theo cu trc a phng).2.3.1.1. S nhn (acknowledgment): ch nguyn thy

Khi s cp nht t ng gi c gi t mt h thng n h thng khc, ch nhn ny ch ra rng n c nhn cp ng dng. L do l n khng bit h thng truyn thng lp di m bo phn pht bn tin. N cng cn bit rng ng dng nhn x l d liu thnh cng ti mc ng dng a phng.

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S nhn c th cha d liu quan tm n h thng khi to vic trao i. VD, nu mt h thng chm sc bnh nhn x l s kin kch khi mt xt nghim c yu cu cho mt bnh nhn, n c th gi mt s cp nht t ng n ng dng xt nghim xc nh bnh nhn, yu cu xt nghim v cc thng tin khc v yu cu. H thng ph thuc s nhn ra xt nghim yu cu khi n x l thnh cng. Chun HL7 khng gi thit v quyn s hu d liu. N cng khng yu cu quyn s hu ca mnh trn hot ng n sau ca d liu nhn, hoc khng gi nh v thit k hoc kin trc ca h thng ng dng nhn. Phm vi ca HL7 b gii hn c trng k thut ca bn tin gia cc h thng nhn, v s kin kch khi chng. Chun HL7 khng c chc nng gii thch yu cu mt h thng trao chuyn d liu trong bn tin n c s d liu ca n trc khi nhn n. Tt c yu cu l h thng nhn chp nhn trch nhim cho d liu, cung cp kim tra ton vn m s p dng ln d liu t bt c ngun no. tip tc VD trc, h thng ph thuc c th nhn yu cu xt nghim sau khi t n trong mt trnh t u vo. Gi thit duy nht l trnh t u vo vn duy tr cng cp ton vn nh l c s d liu.2.3.1.2. S nhn: ch tng cng

M hnh nhn HL7 c m rng phn bit c s nhn ng dng v chp nhn, nh l cc iu kin m di chng phi c. Vi mt s nhn chp nhn dng, h thng nhn truyn bn tin n ni lu tr an ton theo cch m gii phng h thng gi t nhu cu gi li bn tin. Sau khi bn tin c x l bi h thng nhn, mt s nhn ng dng c th c dng hon li trng thi kt qu ca h thng gi.2.3.1.3. Truy vn

Mt trao i d liu khc xy ra khi mt h thng gi mt truy vn n h thng khc. VD, trong ng dng thng tin, c th c mt s kin kch khi

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mt th tc c ln lch cho bnh nhn ngi cha ng k sn trong c s d liu ca ng dng thng tim. ng dng c th gi mt bn tin yu cu cha m ID ca bnh nhn n h thng qun tr v nhn mt p ng cha d liu cn thit cho php x l yu cu. Giao dch gi yu cu ny l mt truy vn. Thng tin chy gia cc h thng c cha trong p ng. Bn thn p ng khng nhn mt bn tin th 3. Trong tt c trng hp, chun HL7 gm mt trao i n gin bn tin gia mt cp ng dng: s cp nht t ng v s nhn ca n hoc truy vn v p ng ca n. M hnh hot ng lp di l m hnh ca my khch v my ch. Mt ng dng tng tc vi ng dng khc dng mt m s kin m xc nh giao dch. ng dng khc p ng vi mt bn tin m gm d liu hoc mt biu th li. ng dng khi to c th nhn mt trng thi y ra t ng dng khc hoc t phn mm cp thp ch ra rng bn tin ca n khng c nhn ng. Truy vn HL7 c th c t cng thc dng mt trong vi phng php sau: 1. B lc truy vn HL7, nh ngha thng qua on QRD v QRF. Nhng b lc ny h tr nh trong cc n bn trc ca HL7, v c tham kho theo truy vn ch nguyn thy. 2. Ngn ng truy vn nhng chn cu lnh, m ngn ng lm cho h thng truy vn c th nh dng yu cu nh l mt cu lnh truy vn dng t do (free-form), s dng ngn ng truy vn ca s chn la (VD, SQL). 3. Bng yu cu o, c chc nng tng t bn tin Ngn ng truy vn nhng, nhng nh dng nghim ngt hn vi cc phn cch.

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4. Cc yu cu th tc lu tr, m n v ca chng trnh trn h thng p ng m c xy dng tha mn mt truy vn ch nh (VD, nh ngha trc cc truy vn, th tc lu tr SQL) Do cc truy vn nh ngha trc h tr bi HL7 b gii hn v s lng v nh ngha chnh xc, mi truy vn c mt tn th tc lu tr tng ng v danh sch thng s lin i vi n. 5. Cc truy vn lp li s kin, l yu cu cho d liu nh dng nh l bn tin s kin. HL7 bao gm cc cu lnh la chn SQL nh mt phng tin thay th tiu chun la chn truy vn m ha. S thay th ny c ngh nh l mt quy c cho cc phn thc thi, v khng c ng h thng my ch phi h tr SQL chung hoc phi da trn k thut c s d liu c lin quan.2.3.2. Mi trng truyn thng

Chun HL7 nh ngha bn tin khi chng c trao i gia thc th ng dng v th tc dng trao i chng. Nh l n hot ng mt cch khi nim cp 7 ca m hnh ISO cho H thng m kt ni trung gian (Open System Interconnection OSI). N c lin quan chnh vi ni dung d liu v mi tng quan ca bn tin v vi vic truyn thng cc cp ng dng trong iu kin li. Do ti nguyn OSI khng thc thi ton b, nhm lm vic HL7 quan tm n cung cp chun m s hu dng trong thi gian ti. HL7 cng nhn ra rng hin ti v s tip tc quan tm n truyn thng d liu chm sc sc khe gia cc h thng hot ng trong mi trng truyn thng m cung cp mt cp cao v chc nng, nhng s dng ti nguyn khc hn l ISO OSI. Ton b mi trng quan tm ca HL7 gm, nhng khng gii hn :

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a) cc mi trng khng d tnh trc m khng cung cp ngay c s n nh vn chuyn c bn. Cc mi trng bao gm lin kt im n im RS-232, modem, v ngay c LAN, nu s ni kt vi my ch ca chng c lm qua giao tip RS-232. Cho n khi chun cp cao OSI tr thnh thc s ph bin, nhiu giao din ca chm sc sc khe s thc thi trn cc kt ni . Trong mt mi trng nh vy, ti nguyn cp thp hn HL7 (Lower Level Protocols LLP) c th c dng gia cc h thng tng kh nng ca mi trng truyn thng. Ti nguyn cp thp hn HL7 c nh ngha trong hng dn thc thi HL7, khng phi l mt phn chnh thc ca chun. b) cc mi trng m h tr mt cp vn chuyn mnh m, nhng khng ph hp vi yu cu mc cao. iu ny bao gm cc mi trng nh l TCP/IP, DECNET, v SNA. c) ISO v tnh s hu cng vic mng m thc thi n mt dch v trnh din v dch v cp cao khc. IBMs SNA LU6.2 v SUN Microsystems NFS l cc v d v tnh s hu cng vic mng hon chnh. d) hai hay nhiu ng dng ang chy trn cng mt my vt l v/hoc my lun l m khng tch hp cht. Trong nhng mi trng ny, kh nng bn tin c th c cung cp bi mt dch v truyn thng x l trung gian (VD, cc ng (pipelines) trong h thng UNIX). Chun HL7 gi nh rng mi trng truyn thng s cung cp cc kh nng sau: a) s truyn khng li. Cc ng dng c th gi nh rng chng nhn chnh xc tt c byte truyn trong cch chnh xc m chng c gi i. iu ny ngm nh rng vic kim tra li c lm mc thp hn.

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www.bme.vn

Tuy nhin ng dng gi c th khng gi nh rng bn tin c nhn thc s khng nhn mt bn tin nhn. b) s chuyn i k t. Nu 2 my trao i d liu dng cc c trng khc nhau ca cng mt tp k t, mi trng truyn thng s chuyn d liu t mt c trng ny n c trng khc. c) Chiu di bn tin. HL7 khng gii hn v kch c ti a ca bn tin HL7. Chun gi nh rng mi trng truyn thng c th vn chuyn bn tin ca bt k chiu di no m c th cn thit. Thc t, cc mt c th ng t vi gii hn trn cho kch thc bn tin v c th dng ti nguyn bn tin lin tc cho bn tin vt qu gii hn trn.Ch : Ch khi HL7 khng lm gi nh v thit k hoc kin trc ca h thngng dng gi v nhn bn tin HL7, n khng gi nh v mi trng truyn thng n nhng iu k trn. Ngoi ra, t nhng gi nh trn, mi trng truyn thng, gm kin trc ca n, thit k v thc thi l ngoi vng ca HL7.

2.3.3. Bn tin

Mt bn tin l mt n v c s ca trao i d liu gia cc h thng. N gm mt nhm on trong mt trnh t nh ngha. Mi bn tin c mt loi bn tin dng nh ngha mc ch ca n. VD loi bn tin ADT c dng truyn cc phn ca d liu qun tr bnh nhn (ADT - Patient Administration) t h thng ny n h thng khc. M 3 k t cha bn trong mi bn tin xc nh loi ca n. Nhng m ny c lit k trong bng Loi bn tin, ph lc B. S kin th gii tht m khi to mt s trao i bn tin c gi l s kin kch khi. Ph lc B cha cc m i din tt c s kin kch khi nh ngha. Nhng m ny i din cc gi tr nh S kin nhn mt bnh nhn, hoc Mt s kin ngh xy ra. C mt mi lin h mt-nhiu gia loi bn tin v m s kin kch khi. Cng m s kin kch khi c th khng lin i vi nhiu hn mt loi bn tin; tuy nhin mt loi bn tin c th lin i vi nhiu hn mt s kin kch khi.

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Tt c loi bn tin v m s kin kch khi bt u bng k t Z l dng cho bn tin nh ngha a phng. Cc m khng c nh ngha trong chun HL7. Phn ny nh ngha cc thnh phn ca bn tin v cung cp phng php nh ngha bn tin tm tt c dng trong cc phn sau.2.3.4. on

Mt on l mt nhm logic ca cc trng d liu. Cc on ca bn tin c th c bt buc hoc ty chn. Chng c th ch xut hin mt ln trong bn tin hoc chng c th c php lp li. Mi on c cho trc mt tn. Vd, bn tin ADT c th cha cc on sau: on mo u (MSH message header segment), on loi s kin (EVN event type segment), on m bnh nhn (PID patient identify segment), v on thn nhn bnh nhn (NK1 next of kin segment). Mi on c xc nh bi mt m 3 k t c gi l ID on. M ID gn vi cc on khc nhau c lit k trong Ph lc C. Tt c m ID on bt u bng k t Z c dng cho bn tin nh ngha a phng. Cc m nh vy s khng c nh ngha trong chun HL7.2.3.5. Trng

Mt trng l mt chui k t. HL7 khng quan tm h thng thc s lu tr d liu ra sao trong mt ng dng. Khi trng c truyn i, chng c gi nh l cc chui k t. Ngoi tr ni no c ghi ch, trng d liu HL7 c th cha gi tr rng. Vic gi gi tr rng, m c truyn trong du (), th khc vi vic b st mt trng d liu ty chn. S khc bit ny xy ra khi ni dung ca bn tin s c dng cp nht mt b d liu trong c s d liu hn l to ra mt b d liu mi. Nu khng c gi tr no c gi, (ngoi tr b b qun) gi tr c nn gi khng i. Nu gi tr rng c gi i, gi tr c nn c i thnh gi tr rng (xem

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thm phn 2.3.9, QUY TC CU TRC BN TIN, bc 2d). Cc chng khc nhau ca chun cha bng thuc tnh on. Nhng bng ny lit k v m t cc trng d liu trong on v c im cch dng ca chng. Trong vic nh ngha on, thng tin sau c ch nh cho mi trng:2.3.5.1. V tr (th t trong mt on)

Th t thng thng ca trng d liu trong on. Con s ny c dng tham kho n ni trng d liu c ghi. Trong bng thuc tnh on, thng tin ny c cung cp trong ct c nhn SEQ.2.3.5.2. Chiu di ti a

S k t ti a m trng d liu c th c. Chiu di ti a khng phi l khi nim quan trng trong bn tin tm tt hoc quy tc m ha HL7. Chiu di ca mt trng mang tnh quy chun. Tuy nhin trong thc t nhn chung n thng c dn xp trn mt nn c bn ch nh. N c tnh ton bao gm cc k hiu phn tch thnh phn v thnh phn con. Bi v chiu di ti a l chiu di ca mt s kin duy nht, k hiu phn cch s lp li ( \ ) khng cha trong phn tnh ton chiu di ti a (Xem phn 2.3.5.5, S lp li). Trong bng thuc tnh trng thng tin ny cha trong ct c nhn l LEN.2.3.5.3. Loi d liu

S gii hn v ni dung ca trng d liu. C mt s loi d liu c nh ngha bi HL7. Cc loi ny c gii thch trong phn 2.3.7, LOI D LIU. Trong bng thuc tnh on thng tin ny c cung cp trong ct c nhn l DT.2.3.5.4. Ty chn

C hay khng trng l bt buc, ty chn hoc iu kin trong mt on. Cc thit k l: R Bt buc (required)

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O C

Ty chn (optional) iu kin (conditional) v s kin kch khi hoc v vi trng khc. S nh ngha trng theo bng thuc tnh on nn ch nh thut ton m nh ngha iu kin cho trng ny. Khng dng trong s kin kch khi ny. Gi li tng thch phn pha sau (backward) ca cc phin bn trc ca HL7. S nh ngha trng theo bng thuc tnh on nn ch r s ty chn ca trng cho ph hp cc phin bn trc.rng trong nh ngha trng on theo mi bng nh ngha on; nu s ty chn ca trng trong mt on thay i ph thuc vo s kin kch khi, s ty chn cng nn c ti liu r rng.

X B

Ch : i vi phin bn 2.3 v cao hn: s ty chn ca trng nn c ti liu r

Ch : i vi cc trng c nh ngha bi loi d liu HL7 cha nhiu thnh phn hoc thnh phn con, s ty chn ca mt thnh phn hay thnh phn con cho trc phi c ch nh trong cc nh ngha trng chi tit theo bng thuc tnh on hnh thc. (Xem phn 2.3.6, CC K HIU GII HN BN TIN, 2.3.7, LOI D LIU, v 2.3.9, QUY LUT CU TRC BN TIN).

Trong bng thuc tnh on thng tin ny c cung cp trong ct c nhn l OPT.2.3.5.5. S lp li

C hay khng trng lp li. Cc thit k l: N Y (integer) Khng lp li (no repetition) Trng c th lp li mt s ln khng r rng hoc xc nh Trng c th lp li trn s ln ch nh bi s integer

Mi s xy ra c th cha s k t c ch nh bi di ti a ca trng. Trong bng thuc tnh on, thng tin ny c cung cp bi ct c nhn l RP/#.

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2.3.5.6. Bng

HL7 nh ngha mt bng cc gi tr cho trng ny. Mt mc trong ct S Bng c ngha l tn bng v tn thnh phn l tng ng. Cch HL7 nh ngha cc gi tr c ngha cho bng s khc nhau. Cc trng, nh Ni bnh nhn , s phi c gi tr thay i t c quan ny n c quan khc. Cc bng nh vy c thit k do ngi dng hoc HL7 nh ngha mt phn. Ngay c cc bng ny khng c nh ngha trong chun, chng c cho trc mt s ca bng ngi dng nh ngha vic thc thi d dng. Loi d liu IS thng c dng m ha gi tr cho cc bng ny. Ch rng vi bng (VD, s xc nh v tr) c tham kho n tp tin chnh chung. Cc vn khc, nh Loi s kin (Bng HL7 0003), l mt phn ca chun HL7 v chng nh hng n s thc thi bn tin cha chng. Chng b gii hn theo cc gi tr c thit lp bi chun HL7. ID loi d liu hu nh thng dng nht m ha gi tr cho bng HL7. Khi mt bng HL7 tn ti th n c ngh phi s dng. Cc gi tr c lit k trong ph lc A. Cc bng HL7 cng xut hin trong vn bn di nh dng hp chun (standard box format) (VD, bng HL7 0003 Loi s kin). Ngoi ra bng c th c bao gm mt nn ch nh mt pha (site-specific basis). Vn cn c cc trng khc cha gi tr c m ha bng cch tham kho n cc ti liu chun khc. VD, trng m ha cho cc th tc ca th vin c nh ngha bi chun ASTM E1238-94. Loi d liu CE c dng m ha cc gi tr cho nhng trng ny. Cui cng, c vi bng ngi dng nh ngha cha gi tr c th c chun ha qua cc c quan nhng khng th p dng chun vn phng tn ti cho cc c quan . i vi nhng bng ny, mt tp hp cc gi tr ngh c th c lit k trong ph lc A. Nhng gi tr ngh xut hinSVTH: V THANH HONG 17 GVHD: TS. HUNH QUANG LINH



trong vn bn di nh dng khng hp tiu chun (standard non-box format) (VD, bng HL7 0062 L do s kin trong phn M l do s kin). Ngi ta mong ch rng nhng gi tr ny s c s dng ni m kh nng ng dng trong mt c quan v dng nh mt c s cho s m rng khi c yu cu. y ban chc nng thch hp trong HL7 thu ht cc ngh cho cc gi tr thm t cc c quan p dng chun. Cc loi d liu HL7 khc nhau (AD, CD, CE, CF, CK, CM, CN, CP, CQ, CX, DLN, ED, EI, FC, ID, IS, JCC, MO, HD, PL, PPN, PT, QSC, RI, RP, SCV, TQ, VH, XAD, XCN, XON, XPN, v XTN) c dng vn chuyn cc gi tr xp thnh bng, hoc c mt thnh phn cha cc gi tr xp thnh bng. Trong bng thuc tnh on, thng tin ny c cung cp trong ct c nhn l TBL#. Ngoi tr duy nht l loi d liu CE v CF, cha nh danh bng l mt phn ca nh ngha loi d liu.2.3.5.7. S ID

S nguyn nh xc nh duy nht trng d liu thng qua chun. Trong s nh ngha on, thng tin ny c cung cp trong ct c nhn l ITEM #.2.3.5.8. Tn

Tn m t cho trng. Trong bng thuc tnh on thng tin ny c cung cp trong ct c nhn l ELEMENT NAME. Khi s dng cng mt tn trong nhiu hn mt on, n phi c cng loi d liu v cng ngha trong mi on, nhng n s c mt s ID ring bit (xem phn 2.3.5.7, S ID) trong mi on ring bit. trnh s ti ngha ny sinh t s tha thun ny, bt c khi no mt trng c tham kho ti y, tn on v v tr phi lun c i km.2.3.6. K hiu phn nh bn tin (message delimiter)

Trong vic kin to mt bn tin, cc k t c bit chc chn c dng. Chng l k hiu kt thc on, k hiu phn chia trng, k hiu phn

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chia thnh phn, k hiu phn chia thnh phn con, k hiu phn chia s lp li, v k t thot. K hiu kt thc on lun lun l mt k t xung dng (carriage return) (trong m ASCII l 0D c s 16). Cc k hiu phn nh khc c nh ngha trong on mo u MSH, vi k hiu phn nh trng v tr k t th 4, v k hiu phn nh khc xy ra khi trong trng c gi l k t m ha, m l trng u tin sau on ID. Gi tr k hiu phn nh trong on MSH l gi tr phn on c dng sut ton b bn tin. Trong vic thiu st ca cc s cn nhc khc, HL7 yu cu s dng cc gi tr ngh tm thy trong Hnh 2-1 cc gi tr phn nh. bt k phng din no cho trc, tp hp con ca cc k hiu phn nh c th c th c gii hn bi s dn xp gia cc ng dng. iu ny ng rng cc ng dng nhn s dng nhng k hiu phn nh chp nhn trn, khi chng xut hin trong on mo u (Message Header segment MSH), phn tch t loi bn tin. Hnh 2-1. Cc gi tr ca k hiu phn nh

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K hiu phn on K hiu kt thc on

Gi tr ngh V tr k t m ha hex 0D | -

Cch dng Kt thc mt b d liu ca on. Gi tr ny khng th c i bi k hiu thc thi. Phn cch 2 trng d liu k nhau trong mt on. N cng phn cch on ID t trng d liu u tin trong mi on. Phn cch cc thnh phn k nhau ca trng d liu ni m c php. Phn cch cc thnh phn con k nhau ca trng d liu ni m cho php. Nu khng c cc thnh phn con, k t ny c th c b qua. Phn cch s xut hin nhiu ln ca mt trng ni m cho php. K t thot dng vi bt k trng no i din bi mt loi d liu ST, TX hoc FT, hoc dng vi thnh phn d liu (th t) ca loi d liu ED. Nu khng c k t thot no c dng trong bn tin, k t ny c th c b qua. Tuy nhin, n phi c hin hu nu cc thnh phn con c dng trong bn tin.

K hiu phn cch trng

-

K hiu phn cch thnh phn

^

1

K hiu phn cch thnh phn con

&

4

K hiu phn cch s lp li

~

2

K t thot

\

3

2.3.7. Loi d liu

Loi d liu trong phn ny c lit k theo th t alphabet.Ch : i vi loi d liu cha cc thnh phn hoc cc thnh phn con nhiu ln, VD cho trong phn ny khng ch nh s ty chn ca thnh phn hoc thnh phn con. iu ny phi c ch nh trong s nh ngha trng theo bng thuc tnh on hnh thc c c di ti a 64K.

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Ngoi tr loi d liu TS v chiu di ti a hoc ti thiu cho vi loi d liu khc (CE, PN, TX, FT), di trng ca cc thuc tnh HL7 c ch nh trong bng thuc tnh on, v bt k di ch nh no ca cc thnh phn hoc thnh phn con ca nhng thuc tnh ny phi c ch nh trong cc nh ngha trng theo bng thuc tnh on hnh thc. Nhn chung, HL7 khng ch nh cc di ca cc thnh phn v/hoc cc thnh phn con. Cc v d loi d liu trong tiu chun ny c cho dng quy tc m ha HL7, vi cc gi tr ca k hiu phn nh t Hnh 2-1 ca phn 2.3.6, CC K HIU PHN NH BN TIN. Mc d ch mt tp hp cc quy lut m ha c nh ngha nh mt tiu chun trong HL7 phin bn 2.3, cc quy tc m ha khc l c th (nhng do chng khng l chun, chng c th ch c dng bi s tha thun ch nh mt pha). Trong cc nh ngha loi d liu no , ngoc vung [ v ] c dng ch cc phn ty chn ca loi d liu (hoc ca loi d liu thnh phn hoc thnh phn con). Hnh 2-2. Loi d liu HL7Loi d liu Kiu va ch va s ST TX FT Chui (String) D liu vn bn (Text data) Vn bn nh dng (Formatted text) S lng ghp vi n v (Composite quantity with units) Tin t (Money) S hc (Numeric) ^ Tn loi d liu Ghi ch/nh dng

Kiu s CQ

MO NM

^

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SI SN Kiu nhn dng (Identifier ID) ID IS

Th t nhn dng (Sequence ID) S hc cu trc ^ ^ (Structured numeric) ^

M ha cc gi tr cho bng HL7 M ha cc gi tr cho bng do ngi dng nh ngha Nhn dng phin bn (Version identifier) ^ ^ ^ ^ ^ ^ Loi x l (Processing type) ^

PT Kiu ngy gi (Date/Time) DT TM TS M cc gi tr (Code Values) CE

Ngy (Date) Thi gian (Time) Du thi gian (Time stamp)

YYYY[MM[DD]] HH[MM[SS[.S[S[S[S]]]]]][+/-ZZZZ] YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/ZZZZ] ^

Yu t m ha (Coded element)

^ ^ ^ ^ ^ ^ ^ ^

CNE

M ha khng cn loi tr (Coded with

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no exceptions)

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

CWE

M ha c loi tr (Coded with exceptions)

CF

Yu t m ha vi gi tr c nh dng (Coded element with formatted values)

CK

ID i km vi s ^ ^ ^ < phn ID with check digit) quyn (HD)> S ID i km v tn (Composite ID number and name) ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ phn quyn (HD)> ^ ^ < phn cp (HD)> Trong phin bn 2.3, dng loi d liu ny thay cho loi d liu CN. ^ &

CN

CX

M rng ID km vi s kim tra (Extended composite ID with check digit) M rng s ID i km v tn (Extended composite ID number and name)

XCN

Tng th (Generic) CM Thnh phn i km (Composite) Khng c loi d liu CM mi c cho php sau phin bn HL7 2.2. Do khng c loi d liu CM mi trong phin bn 2.3. ^ < s thit k khc (ST)> ^ ^

Nhn khu hc AD a ch (Address)

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^ ^ ^ ^ PN Tn ngi (Person name) ^ ^ ^ ^ ^

TN XAD

S in thoi [NN] [(999)]999-9999[X99999][B99999][C vn (Telephone number) bn bt k] a ch m rng (Extended address) Trong phin bn 2.3, thay loi d liu AD. ^ ^ ^ ^ ^ ^ < loi a ch (ID)> ^ ^ ^ ^ Trong phin bn 2.3, thay loi d liu PN. ^ & ^ ^ ^ ^ ^ ^ < m tn i din (ID)> ^ ^ ^ ^ ^ ^ ^ ^ Trong phin bn 2.3, thay loi d liu TN. [NNN] [(999)]999-9999 [X99999] [B99999] [C vn bn bt k] ^ ^ ^ ^ ^ ^ ^ ^

XPN

Tn ngi m rng (Extended person name)

XON

Tn ghp m rng v s ID cho t chc (Extended composite name and ID number for organizations) S vin thng m rng (Extended telecommunications number)

XTN

c bit/ Chng ch nh (Specialty/Cha pter Specific) Dng sng (Waveform) CD nh ngha knh (Channel definition) Ch dnh cho d liu dng sng. ^ & ^ ^ ^ ^ ^ MA Ma trn a chiu (Multiplexed array) Ch dnh cho dng sng. ^ ^ ...~ ^ ^ ...~

NA

Ma trn s (Numeric Ch dnh cho d liu dng sng. array) ^ ^ ^ ^ ... D liu ng gi H tr m ha chun ASCII MIME ca d liu (Encapsulated data) c s 2 ^ ^ ^ ^

ED

Gi ca d liu (Price Data) CP Gi ghp (Composite price) Trong phin bn 2.3, thay loi d liu MO. ^ ^ ^ ^ ^

Qun tr bnh nhn/ Thng tin ti chnh (Patient Administration/ Financial Information) FC Lp ti chnh (Financial class) ^

Cc truy vn m rng (Extended Qeries) QSC Truy vn la chn gii hn (Query selection criteria) Danh sch tham s truy vn u vo (Query input parameter list) ^ ^ ^ ^

QIP

RCD

nh ngha hng ct ^ ^ (Row column definition)

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Tp tin chnh (Master Files) DLN JCC VH S bng li (Drivers ^ ^ M /lp cng vic (Job code/class) Gi ving thm (Visiting hours) ^ ^ ^ ^

H s y khoa /Qun l thng tin (Medical Records/Inform ation Management) PPN nh du thi gian trnh din ngi ( Performing person time stamp) ^ ^ & ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ < ngy gi din ra trnh din (TS)> ^

Chui thi gian (Time Series) DR Khong ngy/gi (Date/time range) Khong thi gian trung gian lp li (Repeat interval) Cp gi tr lp lch trnh (Scheduling class value pair) nh thi /S lng (Timing/quantity) Ch ln lch: ^ Ch ln lch: ^ Ch ln lch: ^ c c trng k thut nh thi /s lng. ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

RI

SCV

TQ

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2.3.8. S dng cc trnh t thot ra trong trng vn bn 2.3.8.1. nh dng m

Khi mt trng ca loi d liu TX, FT hoc CF c dng m ha, k t thot c th c dng bo hiu cc c im c bit no ca cc phn trong trng vn bn. K t thot ra l k t ASCII c th hin th c ch nh trong thnh phn k t thot ca trng MSH-2-cc k t m ha. Trong mc ch ca phn ny, k t \ s c dng i din k t c thit k trong mt bn tin. Mt trnh t thot ra gm k t thot theo sau bi mt m ID thot ca mt k t, zero (0) hoc nhiu k t d liu v s xy ra khc ca k t thot. Cc trnh t thot sau c nh ngha: \H\ \N\ \F\ \S\ \T\ \R\ \E\ \Xdddd...\ \Zdddd...\ Bt u t ni (highlight) Vn bn thng (kt thc t ni) K hiu phn cch trng K hiu phn cch thnh phn K hiu phn cch thnh phn con K hiu phn cch s lp li K t thot D liu c s 16 nh ngha a phng v trnh t thot

Trnh t thot cho k hiu phn cch trng, thnh phn, thnh phn con, s lp li v k t thot cng c gi tr trong mt trng d liu ST. Khng c trnh t thot cha trong b lng cc trnh t thot.2.3.8.2. T ni (highlighting)

Trong thit k t ni, ng dng gi c nhn dng rng cc k t m theo sau nn c ng ring ra, nhng b phng php lm nh vy i vi ng dng nhn. Ph thuc vo c im thit b v s lin h kiu ng dng, ng dng nhn c th chn o ngc video, t m, gch di,

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www.bme.vn

chp tt, mt mu no hoc cc phng tin khc t ni d liu hin th. VD trong mt on bn tin:DSP| TOTAL CHOLESTEROL \H\240*\N\ [90 - 200]

D liu xut hin trn mn hnh bo co hoc bo co c th l:TOTAL CHOLESTEROL 240* [90 - 200]

Trong h thng c th chn hin th 240* mu .2.3.8.3. K t c bit

Trnh t thot k t c bit (\F\, \S\, \R\, \T\, v \E\) cho php k t ph hp c cha trong d liu ca trng vn bn, mc d k t tht s c bo tn. VD:DSP| DSP| TOTAL CHOLESTEROL \S\----------------\S\ 180 \F\90 - 200\F\

S to ra thng tin sau cho phn hin thTOTAL CHOLESTEROL ^----------------^ 180 |90 - 200|

2.3.8.4. Vn bn nh dng

Nu trng ca vn bn thuc loi d liu nh dng, lnh nh dng cng c bao quanh k t thot. Mi ln bt u bng k t (.). Cc lnh nh dng sau: .sp Kt thc u ra hin ti v b qua khong trng dc. l mt s nguyn hoc khng c. Nu khng c, b qua mt khong trng. V tr k t ngang gi khng i. Ch rng ph hp vi phin bn trc, ^\.sp\ tng ng vi \.br\. Bt u mt ng ng ra mi. t v tr ngang n l tri hin ti v tng v tr dc ln 1. Bt u ch ng gi (wrap) hoc lm y (fill) ch. y l trng thi mc nh. N c th b thay i thnh ch

.br .fi

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khng ng gi bng cch dng lnh (.nf) .nf .in Bt u ch khng ng gi. khong trng tht vo, trong l mt s nguyn dng hoc m. Lnh ny khng th xut hin sau k t c th in u tin ca mt dng. Tm thi tht vo khong trng, trong s l mt s nguyn dng hoc m. Lnh ny khng th xut hin sau k t c th in u tin ca mt dng. B qua khong trng v bn phi. Ra cui dng u ra hin ti v vo gia dng tip theo. Hnh 2-3 l mt v d v loi d liu FT t bo co bc x. Hnh 2-3. Vn bn nh dng khi truyn i|\.in+4\\.ti-4\ silhouette is 1. now 2. visible The cardiomediastinal within Lung in the fields left with normal show upper the

.ti

.sk .ce

limits.^\.sp\\.ti-4\ A loop of is of colon

minimal ground glass appearance.^\.sp\\.ti-4\ 3. quadrant appearance distinctly mucosal abnormal effacement

suggesting

colitis.\.in-4\|

Hnh 2-4 cho thy mt cch hin d liu trong Hnh 2-3 . H thng nhn c th to nhiu s th hin khc bng cch thay i l phi. Hnh 2-4. Vn bn nh dng trong mt trnh din c th1. The cardiomediastinal silhouette is now

within normal limits. 2. Lung fields show minimal ground glass

appearance. 3. A loop of colon visible in the left

upper quadrant is distinctly abnormal with the

SVTH: V THANH HONG

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appearance colitis.

of

mucosal

effacement

suggesting

2.3.9. Cc quy lut kin trc d liu

Bc 1: Kin trc on nh ngha bn tin. Mi bn tin c kin trc nh sau: a) 3 k t u l m ID on b) mi trng d liu trong trnh t c chn vo trong on theo cch sau: 1) mt k hiu phn cch trng c t trong on 2) nu mt gi tr khng hin hu, khng bt buc c k t thm 3) nu gi tr hin hu, nhng khng rng, cc k t c t trong trng. 4) nu khng t k t ca gi tr trong on. C thm bao nhiu k t c th sao cho khng vt qu nh ngha ti a cho trng d liu. 5) nu s nh ngha trng gi cho mt trng ph vo cc thnh phn, dng cc quy tc sau: i) nu c nhiu hn mt thnh phn, chng c chia ra bng k hiu phn cch thnh phn. ii) cc thnh phn m hin hu nhng rng c i din bng k t iii) cc thnh phn khng hin hu c i x bng cch thm khng c k t no vo thnh phn. iv) cc thnh phn m khng hin hu cui mt trng khng cn i din bi k hiu phn cch thnh phn. VD, 2 trng d liu l tng ng:SVTH: V THANH HONG 30 GVHD: TS. HUNH QUANG LINH



|ABC^DEF^^| v |ABC^DEF|.

6) nu nh ngha thnh phn gi cho mt thnh phn ph vo thnh phn con, s dng cc quy tc sau: i) nu c nhiu hn mt thnh phn con, chng c chia ra bi mt k hiu thnh phn con. ii) cc thnh phn con m hin hu nhng khng rng c i din bng k t iii) cc thnh phn con khng hin hu c i x bng cch khng cha k t trong thnh phn con. iv) cc thnh phn con khng hin hu cui mt thnh phn khng cn i din bi k hiu phn tch thnh phn con. VD 2 d liu thnh phn sau l tng ng:^XXX&YYY&&^ v ^XXX&YYY^

7) nu trng nh ngha cho php s lp li trng, dng cc quy tc sau, k t lp li ch s dng nu xut hin hn mt ln truyn tin v c t gia cc ln xut hin. (Nu xut hin 3 ln truyn tin, phi dng 2 k t lp li). Trong v d sau, 2 ln xut hin s in thoi c truyn i:|234-7120~599-1288B1234|

c) lp li bc 1b trong c bt k trng no c gi. Nu tt c trng d liu gi trong nh ngha on khng hin hu th khng bt buc km theo bt k k hiu gii hn no. d) kt thc mi on bng k t xung hng ASCII. Bc 2: lp li bc 1 cho n khi tt c cc on c to ra. Cc quy tc sau p dng nhn bn tin HL7 v chuyn ni dung ca chng thnh gi tr d liu:SVTH: V THANH HONG 31 GVHD: TS. HUNH QUANG LINH



a) b qua cc on, trng, thnh phn, thnh phn con, v s lp li thm ca mt trng m hin hu nhng khng c mong ch b) vi cc on mong ch nhng khng hin hu khi ht ton b trng th khng hin hu c) cc trng v thnh phn mong ch nhng khng c trong mt on xem nh khng hin hu2.3.10. Cu to mt bn tin qun tr bnh nhn

S qun tr bnh nhn bao gm nhiu kiu v chia thnh 51 kiu bn tin c nh du theo k hiu ADT/ACK Axx (ACK Acknowlegment). Trong xx l s t nhin chy t 01 51, Axx l s kin A c s th t xx trong chun HL7, ADT l vit tt Administration (s qun tr), ACK vit tt ca Acknowledgment (s cng nhn). Tt c s kin kch khi xy ra c dng bi mt ADT cp nht t ng v p ng ACK.

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2.4. CU TRC BN TIN NHP VIN [4] Bn tin ng k bnh nhn ADT/ACK (s kin A04)S kin A04 to tn hiu bnh nhn n hoc ng k vo mt thi im no hoc bnh nhn ngoi tr ti khm. Cu trc bn tin

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ADT MSH EVN PID [PD1] [ { NK1 }] PV1 [ PV2 ] [ { DB1 [ { OBX [ { AL1 [ { DG1 [ DRG [ { PR1 [{ROL}] }] [ { GT1 [ { IN1 [ IN2 ] [ {IN3} ] } ] [ ACC ] [ UB1 ] [ UB2 ] ACK MSH MSA [ ERR ] } } } } ] ] ] ] ]

Bn tin ADT Message Header (on mo u) Event Type (on loi s kin) Patient Identification (on xc nhn bnh nhn) Additional Demographics (thng tin nhn khu hc) Next of Kin /Associated Parties (thn nhn) Patient Visit (thng tin nhp vin) Patient Visit Additional Info.(thng tin nhp vin thm) Dissability Information (thng tin khuyt tt) Observation/Result (theo di / kt qu) Allergy Information (thng tin d ng) Diagnosis Information (thng tin chn on) Diagnosis Related Group (chn on lin quan nhm) Procedures (th tc) Role (vai tr) Guarantor (ngi bo lnh) Insurance (bo him) Insurance Additional Info. (thng tin bo him thm) Insurance Addl Info - Cert. (chng nhn bo him)

} ]

Accident Information (thng tin tai nn) Universal Bill Information (thng tin thanh ton) Universal Bill 92 Information (thng tin thanh ton) General Acknowledgment Message Header (mo u bn tin) Message Acknowledgment (s chp nhn bn tin) Error (li)

2.4.1. on mo u bn tin (MSH Message Header Segment)

y cng l on cha cc thng s kim sot bn tin. on MSH nh ngha mc ch, ti nguyn, ni n, v cc ch nh ng php ca bn tin. Hnh 2-5. Cc thuc tnh on MSH

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SEQ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

LEN 1 4 180 180 180 180 26 40 7 20 3 60 15 180 2 2 2 10 60 20

DT ST ST EI EI EI EI TS ST CM ST PT VID NM ST ID ID ID ID CE ID

OPT R R O O O O O O R R R R O O O O O O O O

RP/#

TBL#

ITEM # 00001 00002 00003 00004 00005 00006 00007 00008

ELEMENT NAME K hiu phn cch trng K t m ha ng dng gi Kh nng gi d dng ng dng nhn Kh nng nhn d dng Ngy/Gi bn tin Bo mt Loi bn tin ID kim sot bn tin X l ID ID phin bn S trnh t im lin tc Loi chp nhn ng Loi chp nhn ng dng M quc gia Tp hp k t Ngn ng chnh ca bn tin S sp xp tp hp k t thay th

0076 0003

00009 00010 00011

0104

00012 00013 00014

0155 0155 Y 0211

00015 00016 00017 00692 00693 01317

2.4.1.0. nh ngha cc trng trong on MSH 2.4.1.1. K hiu phn cch trng (ST) 00001

nh ngha: Trng ny cha cc k hiu phn cch gia ID on v trng thc u tin, l trng MSH-2-k t m ha. N dng nh l k t phn cch. Gi tr ngh l |, (ASCII 124).2.4.1.2. K t m ha (ST) 00002

nh ngha: Trng ny cha 4 k t theo th t sau: k hiu phn cch thnh phn, k hiu lp li, k t thot, v k hiu phn cch thnh phn con. Gi tr ngh l ^~\&, (ASCII 94, 126, 92, v 38, ln lt)2.4.1.3. ng dng gi (EI) 00003Cc thnh phn: ^ ^

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nh ngha: Trng ny xc nh duy nht ng dng gi gia tt c ng dng khc trong cng trnh mng. Cng trnh mng gm tt c cc ng dng ny m tham gia vo trao i bn tin HL7 trong cng trnh.2.4.1.4. Kh nng gi d dng (Sending facility) (EI) 00004Cc thnh phn: ^ ^

nh ngha: Trng ny cha a ch ca mt vi s xy ra ca cng ng dng trong h thng gi. Ngi dng nh ngha ton b.2.4.1.5. ng dng nhn (EI) 00005Cc thnh phn: ^ ^

nh ngha: Trng ny xc nh duy nht ng dng nhn gia tt c ng dng khc trong cng trnh mng. Cng trnh mng gm tt c cc ng dng ny m tham gia vo trao i bn tin HL7 trong cng trnh.2.4.1.6. Kh nng nhn d dng (Receiving facility) (EI) 00006Cc thnh phn: ^ ^

nh ngha: Trng ny xc nh ng dng nhn gia cc ng dng xc nh tc thi ang chy vi t cch i din cc t chc khc.2.4.1.7. Ngy/Gi bn tin (TS) 00007

nh ngha: Trng ny cha ngy/gi m h thng gi to ra bn tin. Nu thi gian ci t nh dng thi gian, n s dng sut bn tin theo nh dng kiu thi gian mc nh.2.4.1.8. Bo mt (ST) 00008

nh ngha: Trong vi ng dng ca HL7, trng ny c dng thc thi c tnh bo mt.2.4.1.9. Loi bn tin (CM) 00009Cc thnh phn: ^ ^

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nh ngha: Trng ny cha loi bn tin, s kin kch khi, v m cu trc tm tt bn tin cho bn tin. Thnh phn th nht l loi bn tin hiu chnh bi Bng HL7 0076 Loi bn tin; thnh phn th 2 l m s kin kch khi hiu chnh bi Bng HL7 0354 Cu trc bn tin. H thng nhn dng trng ny nhn dng cc on d liu, lm cho ng dng c th truy cp bn tin. i vi cc truy vn no , c th c nhiu hn mt loi s kin p ng n, thnh phn th 2 thay i ch hng cho p ng loi s kin.2.4.1.10. ID kim sot bn tin (ST) 00010

nh ngha: Trng ny cha mt s hoc cc nh danh khc m xc nh duy nht bn tin. H thng nhn phn hi ID ny tr li h thng gi trong on chp nhn bn tin (MSA).2.4.1.11. X l ID (PT) 00011Cc thnh phn: ^

nh ngha: Trng ny c dng quyt nh c hay khng vic x l bn tin nh nh ngha trong cc quy tc x l ng dng (cp 7) ca HL7 trn. Thnh phn u nh ngha c hay khng bn tin l phn ca mt sn phm, o to, hoc g ri h thng (xem Bng HL7 0103 X l ID c cc gi tr ng). Thnh phn th 2 nh ngha c hay khng bn tin l phn ca mt x l nn hoc mt khi to np (xem Bng HL7 0207 Ch x l c cc gi tr ng). Bng 0103 X l IDGi tr D P T M t G ri (Debugging) Sn phm (Production) Hun luyn (Training)

Bng 0207 Ch x l

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Gi tr A R I not present

M t Nn (Archive) Gii nn (Restore from archive) Khi to np (Initial load) Khng hin hu

2.4.1.12. ID phin bn (VID) 00012Cc thnh phn: ^ ^

nh ngha: Trng ny c ph hp bi h thng nhn phin bn chnh n m bo rng bn tin s c gii thch chnh xc. Trong phin bn 2.3.1 c 2 thnh phn quc t ha dng cho cc t chc HL7 quc t. M quc t ha l loi d liu CE (dng m quc gia ISO) m i din bi t chc HL7. ID phin bn quc t c dng nu T chc HL7 c nhiu hn mt phin bn a phng kt hp vi phin bn n ca Hoa K. ID phin bn quc t c loi d liu CE.2.4.1.13. S th t (NM) 00013

nh ngha: Mt gi tr khng rng trong trng ny ng rng ti nguyn s trnh t l c dng. Trng s c tng ln 1 cho mi gi tr trnh t con.2.4.1.14. im lin tc (ST) 00014

nh ngha: Trng ny c dng nh ngha s lin tc trong cch nh ca ng dng.2.4.1.15. ng loi cng nhn (ID) 00015

nh ngha: Trng ny xc nh cc iu kin ng s cng nhn c bt buc tr v p ng cho bn tin. Yu cu cho ch cng nhn tng cng. Tham kho Bng HL7 0155 Cc iu kin cng nhn ng /ng dng.

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2.4.1.16. Loi cng nhn ng dng (ID) 00016

nh ngha: Trng ny cha cc iu kin m s cng nhn ng dng phi c tr li p ng cho bn tin. Bt buc cho ch cng nhn tng cng. Bng sau cha cc gi tr c th cho trng MSH-15-loi chp nhn ng v trng MSH-16-loi chp nhn ng dng: Bng 0155 Cc iu kin cng nhn ng / ng dngGi tr AL NE ER SU M t Lun lun (Always) Khng bao gi (Never) Ch c iu kin conditions only) li/b qua (Error/reject

Ch c s hon tt thnh cng (Successful completion only)

2.4.1.17. M quc gia (ID) 00017

nh ngha: Trng ny cha quc gia nguyn thy cho bn tin. N s c dng ch yu xc nh cc yu t mc nh, nh l s t tn tin t. ISO 3166 cung cp danh sch m quc gia c dng.2.4.1.18. Tp hp k t (ID) 00692

nh ngha: Trng ny cha tp hp k t cho ton bn tin. Tham kho Bng HL7 0211 Tp hp k t thay th c cc gi tr ng. Bng 0211 cc tp hp k t thay thValue ASCII 8859/1 ISO IR14 ISO IR87 Description Tp hp k t 7-bit c th in c. (y l tp hp mc nh) K t in c t tp hp k t ISO 8859/1 M cho thng tin trao i 1-byte (JIS X 0201-1976) M cho tp k t ha Nht dng trao i thng tin.

2.4.1.19. Nguyn l ngn ng ca bn tin (CE) 00693Cc thnh phn: ^ ^ ^ ^

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^

nh ngha: Trng ny cha nguyn l ngn ng ca bn tin. M t ISO 639.2.4.1.20. Tp hp k t thay th cm tay (ID) 01317

nh ngha: Khi bt k mt tp hp k t thay th no c dng, (ch nh trong thnh phn th 2 hoc sau ca trng MSH-18 Tp hp k t), v nu bt k s sp xp cm tay c bit no cn thit, thnh phn ny ch nh cch dng s sp xp.2.4.2. on loi s kin (Event type segment EVN)

on EVN c dng giao tip cc thng tin s kin kch khi cn thit t h thng nhn. Cc loi d liu ng cho tt c cc phn c cha trong Bng HL7 0003 Loi s kin. Hnh 2-6. Thuc tnh on EVNSEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME

1 2 3 4 5 6

3 26 26 3 60 26

ID TS TS IS XCN TS

B R O O O O Y

0003

00099 00100 00101

M loi s kin Ngy/Gi ghi nhn Ngy /Gi ln k hoch s kin M l do s kin ID b hot ng S kin xy ra

0062 0188

00102 00103 01278

2.4.2.0. Cc nh ngha trng EVN 2.4.2.1. M loi s kin (ID) 00099

nh ngha: Trng ny c gi li ch tng thch vi phn sau. ngh dng thnh phn th 2 (s kin kch khi) ca trng MSH-9-loi bn tin truyn thng tin m loi s kin. Trng ny cha cc s kin tng thch vi s kin kch khi m t.2.4.2.2. Ngy /Gi ghi nhn (TS) 00100

nh ngha: Hu ht h thng s mc nh ngy /gi h thng khi giao dch xy ra, nhng chng cng nn c php ghi .SVTH: V THANH HONG 40 GVHD: TS. HUNH QUANG LINH



2.4.2.3. Ngy/Gi ln k hoch s kin (TS) 00101

nh ngha: Trng ny cha ngy/gi m s kin c ln k hoch. ngh dng trng PV2-8-ngy/gi nhn d kin v PV2-9-ngy/gi ra d kin bt c khi no c th.2.4.2.4. M l do s kin (IS) 00102

nh ngha: Trng ny cha l do cho s kin ny (VD, bnh nhn yu cu, ngh ca bc s, qun l iu tra dn s). Tham kho bng ngi dng nh ngha 0062 L do s kin c cc gi tr ngh. Bng ngi dng nh ngha 0062 L do s kin Gi tr 01 02 03Cc thnh phn:

M t Bnh nhn yu cu (Patient request) Bc s ngh (Physician order) Qun l iu tra dn s (Census management) ^ & ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Cc thnh phn con ca phn quyn: & & Cc thnh phn con ca phn cp: & &

nh ngha: Trng ny xc nh trch nhim c nhn cho vic kch khi s kin.

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2.4.2.6. S kin xy ra (TS) 01278

nh ngha: Trng ny cha ngy/gi m s kin tht s xy ra. VD, s kin chuyn bnh nhn (A02), trng ny s cha ngy/gi m bnh nhn tht s chuyn. Nu s kin b hy, trng ny nn cha ngy/gi m s kin b hy.2.4.3. on xc nhn bnh nhn (Patient Identification segment PID)

on PID c dng bi tt c cc ng dng nh l phng tin chnh trong truyn thng thng tin xc nhn bnh nhn. on ny cha vic xc nh bnh nhn lu di v thng tin nhn khu hc, cho hu ht cc phn n khng thay i thng xuyn. Hnh 2-7. Thuc tnh PID

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www.bme.vnSEQ 1 2 3 LEN DT OPT RP/# TBL# ITEM# 00104 00105 ELEMENT NAME

4 20 20 20 48 48 26 1 48 80 106 4 40 40 60 80 80 20 16 25 20 80 60 1 2 80 60 80 26 1

SI CX CX CX XPN XPN TS IS XPN CE XAD IS XTN XTN CE CE CE CX ST DLN CX CE ST ID NM CE CE CE TS ID

O B R B R O O O O O O B O O O O O O B O O O O O O O O O O O0136 0136 0001

t ID - PID ID bnh nhn Danh snh nh danh bnh nhn ID PID bnh nhn thay th Tn bnh nhn Tn m Ngy/Gi sinh Gii tnh B danh bnh nhn Chng tc a ch bnh nhn M quc gia S in thoi nh S in thoi kinh doanh Ngn ng chnh Tnh trng hn nhn Tn gio M s ti khon bnh nhn S SSN - bnh nhn M s bng li bnh nhn nh danh m Nhm dn tc Ni sinh Ch th sinh bi Th t sinh Cng dn Tnh trng qun ng Quc tch Ngy/Gi t vong bnh nhn Ch th bnh nhn cht

Y Y Y Y

00106

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

00107 00108 00109 00110 00111 00112 0005 00113 00114 0289 00115 00116 00117 0296 0002 0006 00118 00119 00120 00121 00122 00123

Y Y Y Y Y

Y Y0189

00124 00125 00126 00127 00128

Y

0171 0172 0212

00129 00130 00739 00740 00741

2.4.3.0. nh ngha trng PID 2.4.3.1. t ID PID (SI) 00104

nh ngha: Trng ny cha con s m xc nh s giao dch ny. i vi s xy ra u tin ca on, s th t nn l 1, i vi s xy ra th hai, s th t nn l 2

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2.4.3.2. ID bnh nhn (CX) 00105Cc thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &

& Thnh phn con ca phn cp: & &

nh ngha:

Trng ny c gi li ch tng thch vi phn

sau. Trong phin bn HL7 v2.3.1, thut ng ID ngoi b i t tn ca trng ny. S lp li, phn quyn, phn cp v m loi nh danh ca trng PID-3-danh sch nh danh bnh nhn cho php i din nh danh ring bit.2.4.3.3. Danh sch nh danh bnh nhn (CX) 00106Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


nh ngha: Trng ny cha danh sch nh danh (mt hoc nhiu) c dng bi iu kin d dng duy nht xc nh mt bnh nhn (VD, s h s y khoa, s bill, ng k sinh, nh danh quc tch). Trong phin bn HL7 v2.3.1, thut ng ID ni b i t tn ca trng ny r rng.2.4.3.4. ID PID bnh nhn thay th (CX) 00107Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &

&

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Thnh phn con ca phn cp: & &

nh ngha: Trng ny c gi li ch tng thch vi phn sau. ngh dng trng PID-3-danh sch nh danh bnh nhn nh danh tt c bnh nhn.2.4.3.5. Tn bnh nhn (XPN) 00108Thnh phn: & ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha tn hp php ca bnh nhn. Tt c tn khc cho bnh nhn nn c gi trong trng PID-9-b danh bnh nhn. Do , m loi tn trong trng ny nn l L Legal (hp php). Xem bng HL7 0200 Loi tn (Name type) c gi tr ng.2.4.3.6. Tn m (Mothers maiden name) (XPN) 00109Thnh phn: & ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha tn gia nh m ngi m sinh ra (VD, trc hn nhn). N c dng phn bit gia bnh nhn vi cng h.2.4.3.7. Ngy/Gi sinh (TS) 00110

nh ngha: Trng ny cha ngy/gi sinh ca bnh nhn.2.4.3.8. Gii tnh (IS) 00111

nh ngha: Trng ny cha gii tnh bnh nhn. Tham kho bng ngi dng nh ngha 0001-Gii tnh c gi tr ngh. Bng ngi dng nh ngha 0001 Gii tnh Gi tr M t

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F M O UThnh phn:

N (Female) Nam (Male) Khc (Other) Khng bit (Unknown) & ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha tn m bnh nhn c mt lc no . Xem thm bng HL7 0200 Name type c cc gi tr ng.2.4.3.10. Chng tc (CE) 00113Cc thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny ni v chng tc ca bnh nhn. Tham kho bng ngi dng nh ngha 0005- Race c cc gi tr ngh. Cc m ny c thit k bi Vn phng Qun l v Ngn sch ca Hoa k (the Office of Management and Budget).2.4.3.11. a ch bnh nhn (XAD) 00114Thnh phn: ^ ^ ^ ^ ^ ^ < loi a ch (ID)> ^ ^ ^ ^

nh ngha: Trng ny cha a ch th tn ca bnh nhn. M loi a ch c nh ngha bi HL7, xem bng HL7 0190 Address type.

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2.4.3.12. M quc gia (IS) 00115

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Xem bng ngi dng nh ngha 0289 - County/parish.2.4.3.13. S in thoi nh (XTN) 00116Thnh phn: [NNN] [(999)]999-9999 [X99999] [B99999] [C vn ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha s in thoi c nhn ca bnh nhn. Tt c cc s in thoi c nhn bnh nhn c gi theo trnh t sau. Trnh t u tin c lin h vi s chnh. Nu s chnh khng c gi mt k hiu lp li c gi trong trnh t u tin. Tham kho bng HL7 0201 Telecommunication use code v bng 0202 - Telecommunication equipment type c gi tr ng.2.4.3.14. S in thoi kinh doanh (XTN) 00117Thnh phn: [NNN] [(999)]999-9999 [X99999] [B99999] [C vn ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha s in thoi kinh doanh ca bnh nhn. Tt c cc s in thoi kinh doanh bnh nhn c gi theo trnh t sau. Trnh t u tin c lin h vi s chnh. Nu s chnh khng c gi mt k hiu lp li c gi trong trnh t u tin. Tham kho bng HL7 0201 - Telecommunication use code v bng 0202 - Telecommunication equipment type c gi tr ng.

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2.4.3.15. Ngn ng chnh (CE) 00118Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha ngn ng chnh ca bnh nhn. HL7 ngh dng bng ISO 639 c gi tr ngh trong bng ngi dng nh ngha 0296 Language.2.4.3.16. Tnh trng hn nhn (CE) 00119Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha tnh trng hn nhn ca bnh nhn. Tham kho bng ngi dng nh ngha 0002 - Marital status. Gi tr A D M S W2.4.3.17. Tn gio (CE) 00120Thnh phn: ^ ^ ^ ^ ^

M t Ly thn (Separated) Ly d (Divorced) Kt hn (Married) c thn (Single) ga (Widowed)

nh ngha: Trng ny cha tn gio ca bnh nhn, VD Ngi lm l ra ti, Thin cha gio, Hi gim l. Tham kho bng ngi dng nh ngha 0006-Religion.

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2.4.3.18. M s ti khon bnh nhn (CX) 00121Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


nh ngha: Trng ny cha m s ti khon ca bnh nhn gn bi vic to ti khon m tt c np, tr tin c ghi nhn. Dng xc nhn ti khon bnh nhn. Xem bng HL7 0061 - Check digit scheme.2.4.3.19. M s SSN bnh nhn (ST) 00122

nh ngha: Trng ny c gi li ch tng thch vi phn sau. ngh dng trng PID-3-danh sch nh danh bnh nhn.2.4.3.20. M s bng li xe (DLN) 00123Thnh phn: ^ ^

nh ngha: Trng ny cha m s bng li xe ca bnh nhn. Vi ni c th dng s ny nh l s duy nht nh danh bnh nhn. Mc nh ca thnh phn th hai l tiu bang m bng ca bnh nhn ng k.2.4.3.21. nh danh m (CX) 00124Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


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nh ngha: Trng ny c dng nh l mt trng lin kt cho trng hp mi sinh. Mt ID bnh nhn hoc m s ti khon in hnh c th c dng. Trng ny c th cha nhiu nh danh cho cng m.2.4.3.22. Nhm dn tc (CE) 00125Thnh phn: ^ ^ ^ ^ ^

nh ngha:

Trng ny nh ngha dng h ca bnh nhn. Tham kho

bng ngi dng nh ngha 0189- Ethnic group.2.4.3.23. Ni sinh (ST) 00126

nh ngha: Trng ny ch ra a im m bnh nhn sinh ra.2.4.3.24. Ch th sinh bi (ID) 00127

nh ngha: Trng ny ch ra vic c hay khng bnh nhn l mt phn ca s sinh bi. Tham kho bng HL7 0136 - Yes/No indicator.2.4.3.25. Th t sinh (NM) 00128

nh ngha: Khi mt bnh nhn l mt phn ca sinh bi, mt gi tr (s) ch nh th t sinh ca bnh nhn c a vo trng ny.2.4.3.26. Cng dn (CE) 00129Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha quc gia ca cng dn. HL7 ngh dng Bng ISO 3166 c cc gi tr ngh trong bng ngi dng nh ngha 0171 Citizenship.2.4.3.27. Tnh trng qun ng (CE) 00130Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha tnh trng qun ng gn cho mt qun nhn. Tham kho bng ngi dng nh ngha 0172 - Veterans military status.2.4.3.28. Quc tch (CE) 00739Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha mt m xc nh quc gia hoc nhm quc gia m ngi ta thuc v. Thng tin ny c th khc bit t ngi cng dn trong t nc m c a quc tch (VD, Ty Ban Nha: Basque, Catalan). HL7 xut dng bng ISO 3166 c gi tr ngh trong bng ngi dng nh ngha 0212 - Nationality.2.4.3.29. Ngy/Gi bnh nhn t vong (TS) 00740

nh ngha: Trng ny cha ngy v gi khi ci cht bnh nhn xy ra.2.4.3.30. Ch th t vong ca bnh nhn (ID) 00741

nh ngha: Trng ny ch ra vic c hoc khng bnh nhn qua i. Tham kho bng HL7 0136 - Yes/no indicator.2.4.4. on thn nhn bnh nhn (Next of kin / associated parties segment NK1)

on NK1 cha thng tin v thn nhn bnh nhn. S dng trng NK1-1t ID c th gi c ti khon bnh nhn. Nu mt ngi hoc t chc thi hnh vai tr lin lc, VD mt ngi l mt lin h cp cu v mt dng h k, yu cu gi on NK1 cho mi vai tr lin h. Hnh 2-8. Thuc tnh NK1

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SEQ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

LEN 4 48 60 106 40 40 60 8 8 60 20 20 90 80 1 26 2 2 80 60 2 80 1 2 80 48 80 80 80 48 40 106 32 2 80

DT SI XPN CE XAD XTN XTN CE DT DT ST JCC CX XON CE IS TS IS IS CE CE IS CE ID IS CE XPN CE CE CE XPN XTN XAD CX IS CE

OPT R O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

R P/#

TBL#

ITEM# 00190

ELEMENT NAME t ID NK1 Tn Mi quan h a ch S in thoi S in thoi kinh doanh Vai tr lin h Ngy bt u Ngy kt thc Tiu cng vic thn nhn M/Lp cng vic thn nhn M s lao ng ca thn nhn Tn t chc NK1 Tnh trng hn nhn Gii tnh Ngy/Gi sinh Sng l thuc vo (Living Dependency) Tnh trng i li Cng dn Ngn ng chnh S sp xp ni M cng khai Ch th bo v Ch th sinh vin (Student Indicator) Tn gio Tn m Quc tch Nhm dn tc L do lin h Tn ngi lin h S in thoi ngi lin h a ch ngi lin h nh danh thn nhn Tnh trng cng vic Chng tc

Y0063

00191 00192 00193 00194 00195 0131 00196 00197 00198 00199 0327/ 0328 00201 00200

Y Y Y

Y0002 0001

00202 00119 00111 00110

Y Y Y

0223

00755

0009 0171 0296 0220 0215 0136 0231

00145 00129 00118 00742 00743 00744 00745

0006

00120 00746

Y0212

00739 00125 00747 00748 00749 00750 00751

Y Y Y Y Y Y

0189 0222

0311

00752 00113

Y

0005

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36 37

2 16

IS ST

O O

0295

00753 00754

iu bt li S bo him x hi ngi lin h

2.4.4.0. Cc nh ngha trng NK1

Mt s trng trong on NK1 c thuc tnh, loi d liu tng t cc trng trong on PID. y, ch nu nh ngha mt s trng dng trong vic xy dng chng trnh c bn tin.2.4.4.1. t ID NK1 (SI) 00190

nh ngha: Trng ny cha con s m xc nh s giao dch ny. i vi s xy ra u tin ca on, s th t nn l 1, i vi s xy ra th hai, s th t nn l 22.4.4.2. Tn (XPN) 00191Thnh phn: & ^ ^ ^ ^ ^ ^ ^

nh ngha:

Trng ny cha tn ca thn nhn hoc t chc h tr.

Nhiu tn cho cng mt ngi c chp nhn, nhng tn hp php phi c gi trong trnh t u tin. Nu tn hp php khng c gi th phi c k hiu lp gi trong on u tin.2.4.4.3. Mi quan h (CE) 00192Thnh phn: ^ ^ ^ ^ ^

nh ngha:

Trng ny cha mi quan h con ngi tht s m dng

h/t chc h tr c vi bnh nhn. Tham kho bng ngi dng nh ngha 0063 Relationship. VD c th bao gm: anh, ch, cha, me, bn, v (chng), lin h cp cu, ngi ch

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2.4.4.4. M/Lp cng vic ca thn nhn/t chc (JCC) 00200Thnh phn: ^

nh ngha:

Trng ny chc m ngi s dng lao ng v phn lp

ngi lao ng dng cho thn nhn/t chc h tr ni lm vic. Tuy nhin nu ngi lin h l ch ca bnh nhn, trng ny c th cha m/lp cng vic ca bnh nhn ni lm vic ca h. Tham kho bng ngi dng nh ngha 0327 - Job code v 0328 - Employee classification.2.4.4.5. M s cng vic ca dng h/t chc h tr (CX) 00201Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


nh ngha: tng thch vi phn sau, loi d liu ST c th c gi; tuy nhin HL7 nghdng loi d liu CX cho phn thc thi mi. Trng ny cha m s m ngi s dng lao ng gn cho ngi lao ng m l thn nhn. Tuy nhin, nu vai tr lin h l ngi ch bnh nhn, trng ny cha m s lm vic ca bnh nhn ni lm vic ca h.2.4.4.6. Tn t chc NK1 (XON) 00202Thnh phn: ^ ^ ^ ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


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nh ngha: Trng ny cha tn ca t chc m dng nh l thn nhn/t chc h tr ca bnh nhn. Trng ny cng c th c dng lin lc tn ca t chc ni m t chc h tr lm vic.2.4.4.7. Sng l thuc vo (Living dependency) (IS) 00755

nh ngha:

Trng ny xc nh cc iu kin sng ch nh (VD, v

(chng) ph thuc bnh nhn, cn h khng c thang my) m c lin quan n s lng gi nhu cu chm sc sc khe ca bnh nhn. Thng tin ny c th dng cho vic xut vin. VD nh gm V (chng) ph thuc, Nh qun l y khoa, Tr nh ph thuc. Tham kho bng ngi dng nh ngha 0223 Living dependency ly gi tr ngh.2.4.4.8. Tnh trng i li (Ambulatory status) (IS) 00145

nh ngha: ngh.

Trng ny xc nh s di chuyn tm thi ca thn nhn.

Xem bng ngi dng nh ngha 0009 Ambulatory status c gi tr

2.4.4.9. Sp xp ch sng (Living arrangement) (IS) 00742

nh ngha: Trng ny xc nh tnh trng m t chc h tr sng trong a ch nh ring ca anh (ch) y. Tham kho bng ngi dng nh ngha 0220 - Living arrangement c gi tr ngh. VD sp xp ch sng gm Mt mnh, Gia nh, C quan2.4.4.10. M cng khai (Publicity code) (CE) 00743Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny ch ra cp cng khai cho php (VD, Khng cng khai, Ch Gia nh bit) cho thn nhn/t chc h tr. Xem bng ngi dng nh ngha 0215 Publicity code c gi tr ngh.

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2.4.4.11. Ch th bo v (Protection indicator) (ID) 00744

nh ngha: Trng ny xc nh s bo v ca thn nhn/t chc h tr m xc nh ni no truy cp vo thng tin v c nhn ny nn c gi t ngi dng khng c quyn thch hp.2.4.4.12. Ch th sinh vin (Student indicator) (IS) 00745

nh ngha: Trng ny xc nh c hay khng thn nhn/t chc hin ti l mt sinh vin v c hay khng thn nhn/t chc l mt sinh vin bn hoc ton thi gian. Trng ny khng ch r mc (trung hc, i hc) ca sinh vin hoc lnh vc nghin cu. Tham kho bng ngi dng nh ngha 0231 Student status.2.4.4.13. L do lin h (CE) 00747Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny xc nh lm th no vic lin h nn c dng (VD, lin h ngi ch nu bnh nhn khng c kh nng lm vic). Tham kho bng ngi dng nh ngha 0222 Contact reason c gi tr ngh.2.4.4.14. Tn ngi lin h (XPN) 00748Thnh phn: & ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha tn ca thn nhn hoc t chc h tr. Cho php c nhiu tn cho cng mt ngi, nhng tn hp l phi c gi trong trnh t u tin. Nu tn hp l khng c gi th k t lp li phi c gi i trong trnh t u tin.

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2.4.4.15. S in thoi ngi lin h (XTN) 00749Thnh phn: [NNN] [(999)]999-9999 [X99999] [B99999] [C vn ^ ^ ^ ^ ^ ^ ^

nh ngha: Trng ny cha s in thoi ca thn nhn/ t chc h tr. Cho php c nhiu s in thoi cho cng ngi. S in thoi chnh phi c gi trong trnh t u tin. Nu s in thoi chnh khng c gi, th phi c k hiu lp li trnh t u tin.2.4.4.16. a ch ngi lin h (XAD) 00750Thnh phn: ^ ^ ^ ^ ^ ^ < loi a ch (ID)> ^ ^ ^ ^

nh ngha: Trng ny cha a ch ca thn nhn/ t chc h tr. Chp nhn nhiu a ch cho cng ngi. a ch th tn phi c gi trong trnh t u tin. Nu a ch th tn khng c gi th phi c k hiu lp li c gi trong trnh t u tin.2.4.4.17. nh danh thn nhn/t chc h tr (CX) 00751Thnh phn: ^ ^ ^ ^ ^ Thnh phn con ca phn quyn: &


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www.bme.vn

nh ngha: Trng ny cha nh danh cho thn nhn/t chc h tr, VD, M s an ninh x hi, bng li xe Phn quyn v m loi nh danh ngh dng loi d liu CX.2.4.4.18. Tnh trng cng vic (IS) 00752

nh ngha:

Trng ny xc nh tnh trng cng vic ca thn nhn/t

chc (ton thi gian, bn thi gian, thng trc). Tham kho bng ngi dng nh ngha 0311 Job status c cc gi tr ngh.2.4.4.19. Cc kh khn (Handicap) (IS) 00753

nh ngha: Trng ny cha m m t mt s khng c kh nng ca t chc h tr. Tham kho bng ngi dng nh ngha 0259 Handicap c cc gi tr ngh.2.4.4.20. M s bo him x hi ca ngi lin h (ST) 00754

nh ngha: Trng ny cha m s bo him x hi ca ngi lin h. S ny cng c th l mt m s v hu RR. i vi m s bo him x hi ca t chc h tr, xem trng NK1-33-next of kin/associated partys identifiers.2.4.5. on thng tin nhp vin (Patient Visit segment PV1)

on PV1 c dng bi cc ng dng ng k/Qun tr Bnh nhn truyn thng tin trn mt nn ch nh nhp vin. on ny c th c dng gi nhiu h s nhp vin n cng ti khon bnh nhn hoc h s nhp vin n n nhiu hn mt ti khon. Pha c nhn phi xc nh vic dng cho on ny. Hnh 2-9. Thuc tnh PV1

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SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM# 00131

ELEMENT NAME

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

4 1 80 2 20 80 60 60 60 3 80 2 2 3 2 2 60 2 20 50 2 2 2 2 8 12 3 2 1 8 10 12 12 1 8 3 25

SI IS PL IS CX PL XCN XCN XCN IS PL IS IS IS IS IS XCN IS CX FC IS IS IS IS DT NM NM IS IS DT IS NM NM IS DT IS CM

O R O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O0112 0113 0111 0021 0087 0092 0023 0007 0004

t ID - PV1 Lp bnh nhn Gn a im bnh nhn Loi nhn M s nhn trc a im bnh nhn lc trc Bc s chm sc Bc s tham kho Bc s c vn Dch v bnh vin a im tm thi Ch nh xt nghim nhn trc Ch nh ti nhn Ngun nhn Tnh trng i li Ch nh VIP Bc s nhn Loi bnh nhn M s nhp vin Lp ti chnh Ch nh gi phi tr M u i S nh gi mc tn nhim M hp ng Ngy hp ng c hiu lc Lng hp ng Chu k hp ng M quan tm Chuyn n M n khng th tr Chuyn n ngy n khng th tr M c quan n khng th tr Lng chuyn n khng th tr Lng hon tr n khng th tr Ch th xa ti khon Ngy xa ti khon S sp xp ra vin Chuyn ra n a im khc

00132 00133 00134 00135 00136

Y Y Y

0010 0010 0010 0069

00137 00138 00139 00140 00141 00142 00143 00144 00145 00146 00147 00148 00149

Y Y

0009 0099 0010 0018

Y

0064 0032 0045 0046

00150 00151 00152 00153 00154 00155 00156 00157

Y Y Y Y

0044

0073 0110

00158 00159 00160

00161 00162 00163 00164 00165 00166 00167

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SEQ

LEN

DT

OPT

RP/#

TBL# 0114 0115 0116 0117

ITEM# 00168 00169 00170 00171 00172 00173 00174 00175 00176 00177 00178 00179

ELEMENT NAME

38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

80 2 1 2 80 80 26 26 12 12 12 12 20 1 60

CE IS IS IS PL PL TS TS NM NM NM NM CX IS XCN

O O B O O O O O O O O O O O O Y

Loi king n iu kin dch v d dng Tnh trng ging Tnh trng ti khon a im cha gii quyt a im tm trc Ngy/Gi Nhn Ngy/Gi ra vin Cn bng bnh nhn hin ti Tng tin phi tr Tng iu chnh Tng tin tr ID nhp vin thay th Ch th ngi nhp vin Nh cung cp chm sc sc khe khc

0203 0326 0010

00180 01226 01274

2.4.5.0. Cc nh ngha trng PV1 2.4.5.1. t ID PV1 (SI) 001

nh ngha: Trng ny cha con s m xc nh s giao dch ny. i vi s xy ra u tin ca on, s th t nn l 1, i vi s xy ra th hai, s th t nn l 22.4.5.2. Lp bnh nhn (IS) 00132

nh ngha: Trng ny c dng bi h thng phn loi bnh nhn theo mt no . N khng c mt nh ngha kin nh theo quy m cng nghip rng. Tham kho bng ngi dng nh ngha 0004 Patient class c gi tr ngh. Bng ngi dng nh ngha 0004 Patient class Gi tr E I O P M t Cp cu (Emergency) Bnh nhn ni tr (Inpatient) Bnh nhn ngoi tr (Outpatient) Nhn trc (Preadmit)

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R B

Bnh nhn ti khm (Recurring Patient) Sn ph (Obstetrics) ^ ^ ^ ^ < tnh trng ni nm (IS )> ^ ^ ^ ^ Thnh phn con ca iu kin d dng: & &

nh ngha: Trng ny cha a im gn cho bnh nhn ban u hoc a im m bnh nhn ang chuyn i. Thnh phn th nht c th l trm y t cho a im bnh nhn ni tr, hoc lm sng, b phn, hoc nh cho a im khc bnh nhn ni tr. hy giao dch hoc xut vin mt bnh nhn, a im hin ti (sau s kin hy hoc trc s kin xut vin) nn trong trng ny. Nu mt gi tr tn ti trong thnh phn th 5 (tnh trng ging), n thay th gi tr trong trng PV1-40-tnh trng ging.2.4.5.4. Loi nhn (Admission type) (IS) 00134

nh ngha: gi tr ngh.

Trng ny ch r trng hp m bnh nhn l hoc c

nhn. Tham kho bng ngi dng nh ngha 0007 Admission type c

Bng ngi dng nh ngha 0007 Admission type Gi tr A E L R M t Tai nn (Accident) Cp cu (Emergency) Ct cn d con v sinh (Labor and Delivery) Th tc (Routine) ^ & Thnh phn con ca phn quyn: &


nh ngha: Trng ny cha thng tin bc s chm sc. Nhiu tn v nh danh cho cng bc s c th c gi. Trnh t trng khng c dng ch nh nhiu bc s chm sc. Tn hp php phi c gi trong trnh t u tin. Nu tn hp l khng c gi th mt k hiu lp li phi c gi trong trnh t u tin. Ph thuc vo s ng a phng, c ID hoc tn c th c vng mt trong trng ny. Tham kho bng ngi dng nh ngha 0010 Physician ID c gi tr ng.2.4.5.6. Dch v bnh vin (IS) 00140

nh ngha: Trng ny cha s iu tr hoc loi phu thut m bnh nhn c ln lch nhn. Trng bt buc vi s kin kch khi A01 (khai bo nhn/nhp vin), A02 (chuyn mt bnh nhn), A14 (s nhn sp xy ra), A15 (s chuyn sp xy ra). Tham kho bng ngi dng nh ngha 0069 Hospital service c cc gi tr ngh.2.4.5.7. Ngun nhn (IS) 00144

nh ngha: Trng ny ch th ni m bnh nhn c nhn. Tham kho bng ngi dng nh ngha 0023 Admit source c cc gi tr ngh. Trng ny c dng theo m UB92 FL19. Bng ngi dng nh ngha 0023 Admit source Gi tr 1 M t Tham kho Bc s (Physician Referral)

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Gi tr 2 3 4 5 6 7 8 9

M t Tham kho chuyn khoa (Clinic Referral) Tham kho HMO (HMO Referral) Chuyn t mt bnh vin (Transfer from a Hospital) Chuyn t mt t y t chuyn nghip (Transfer from a Skilled Nursing Facility) Chuyn t t chc chm sc sc khe khc (Transfer from Another Health Care Facility) Phng cp cu (Emergency Room) S thc p ca ta n (Court/Law Enforcement) Thng tin khng c sn (Information Not Available)

2.4.6. on thng tin chn on (Diagnosis segment DG1)

on DG1 cha thng tin chn on bnh nhn ca nhiu loi. on DG1 c dng gi nhiu chn on. N cng dng khi trng FT1-19diagnosis code khng cung cp thng tin cho h thng tnh tin. Vic m ha chn on ny nn tch ring ra t on vn lm sng dng bi cc nh quan tm qun l bnh nhn. Cc phng php m ha cng c nh ngha. Hnh 2-10. Thuc tnh on DG1

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SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM# 00375

ELEMENT NAME

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

4 2 60 40 26 2 60 60 2 2 60 3 12 4 2 60 3 1 26

SI ID CE ST TS IS CE CE ID IS CE NM CP ST ID XCN IS ID TS

R (B) R O B O R B B B B B B B B O O O O O Y0228 0136 0052 0118 0055 0053

t ID - DG1 Phng php m ha chn on M chn on DG1 M t chn on Ngy/Gi chn on Loi chn on Mc chn on ch yu Nhm lin quan chn on Ch th chp thun DRG M xem li nhm DRG Ngoi loi Ngoi ngy Ngoi gi Phin bn nhm v loi u tin chn on Chn on lm sng Phn loi chn on Ch th b mt Ngy/Gi chng thc

00376

0051

00377 00378 00379 00380 00381 00382

0136 0056 0083

00383 00384 00385 00386 00387 00388 00389 00390 00766 00767 00768

2.4.6.0. Cc nh ngha trng DG1 2.4.6.1. t ID DG1 (SI) 00375

nh ngha: Trng ny cha con s m xc nh s giao dch ny. i vi s xy ra u tin ca on, s th t nn l 1, i vi s xy ra th hai, s th t nn l 22.4.6.2. Phng php m ha chn on (ID) 00376

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Dng thnh phn ca trng DG1-3-diagnosis code thay cho trng ny. Khi dng cho s tng thch phn sau, ICD9 l phng php m ha ngh. Tham kho bng HL7 0053 Diagnosis coding method c gi tr ng.

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2.4.6.3. M chn on - DG1 (CE) 00377Thnh phn: ^ ^ ^ ^ ^

nh ngha:

Dng trng ny thay cho trng DG1-2-coding method v

DG1-4-diagnosis description. Tham kho bng ngi dng nh ngha 0051 Diagnosis code c gi tr ngh. Trng ny l mt loi d liu CE tng thch vi h thng lm sng v h thng ph thuc.2.4.6.4. M t chn on (ST) 00378

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Dng cc thnh phn ca trng DG1-3-diagnosis code thay cho trng ny. Khi dng tng thch phn sau, DG1-4-diagnosis description cha mt m t m m t tt nht cho chn on.2.4.6.5. Ngy/Gi chn on (TS) 00379

nh ngha: Trng ny cha ngy/gi vic chn on xc nh.2.4.6.6. Loi chn on (IS) 00380

nh ngha: Trng ny cha mt m xc nh loi ca chn on ang c gi. Tham kho bng ngi dng nh ngha 0052 Diagnosis type. Trng ny khng nn c dng na ch nh DRG bi v trng DRG di chuyn n on DRG mi. User-defined (Ngi dng nh ngha) Table 0052 - Diagnosis type Gi tr A W FThnh phn:

M tNhn vo (Admitting)

Lm vic (Working) Cui cng (Final)

2.4.6.7. Mc chn on chnh (CE) 00381 ^ ^ ^ ^ ^

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny ch nn c dng trong s giao dch file chnh. Tham kho bng ngi dng nh ngha 0118 Major diagnosis category c gi tr ngh.2.4.6.8. Nhm quan h chn on (CE) 00328Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny c di n on DRG mi. N cha thng tin DRG cho giao dch. Tm thi DRG c th c xc nh bt thnh lnh. Tham kho bng ngui dng nh ngha 0055 DRG code c gi tr ngh.2.4.6.9. Ch th chp thun DRG (DRG approval indicator) (ID) 00383

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny di n on DRG mi. Trng ny ch ra nu DRG c chp thun bi mt thc th xem li. Tham kho bng HL7 0136 Yes/No indicator c gi tr ng.2.4.6.10. M xem li nhm DRG (DRG grouper review code) (IS) 00384

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny di n on DRG mi. Tham kho bng ngi dng nh ngha 0056 DRG grouper review code c gi tr ngh. M ny ch ra rng cc kt qu nhm c xem li v chp thun.2.4.6.11. Ngoi loi (Outlier type) (CE) 00385Thnh phn: ^ ^ ^ ^ ^

SVTH: V THANH HONG

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nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny di n on DRG mi. Khi dng cho vic tng thch vi phn sau, trng ny cha loi thuc bn ngoi m c tr. Tham kho bng ngi dng nh ngha 0083 Outlier type c cc gi tr ngh.2.4.6.12. Ngoi ngy (Outlier Days) (NM) 00386

nh ngha: Trng ny c gi li ch tng thch vi phn sau. Trng ny di n on DRG mi. Khi dng cho vic tng thch vi phn sau, trng ny cha s ngy m c chp thun cho mt s tin tr ngoi.2.4.7. on thng tin bo him (Insurance segment IN1)

on IN1 cha chnh sch bo him bao trm ln thng tin cn thit to ra mt ha n chia theo t l chnh xc v ha n bnh nhn, ha n bo him. Hnh 6-6. Thuc tnh IN1SEQ LEN DT OPT RP/# TBL# ITEM# 00426 0072 00368 00428 00429 00430 00431 ELEMENT NAME

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

4 60 59 130 106 48 40 12 130 12 130 8 8 55 3

SI CE CX XON XAD XPN XTN ST XON CX XON DT DT CM IS

R R R O O O O O O O O O O O O0086

t ID - IN1 ID k hoch bo him ID cng ty bo him Tn cng ty bo him a ch cng ty bo him Ngi ng lin lc bo him in thoi ngi ng lin l M s nhm Tn nhm ID nhm ngi lao ng c bo him Tn nhm ngi lao ng c bo him Ngy d nh c hiu lc Ngy d nh ht hn Thng tin bn quyn Loi d nh

Y Y Y Y Y

00432

00433

Y Y Y

00434 00435

00436

00437 00438 00439 00440

SVTH: V THANH HONG

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SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM# 00441

ELEMENT NAME

16 17

48 80

XPN CE

O O

Y0063

Tn ca ngi c bo him Mi quan h ca ngi c bo him vi bnh nhn Ngy sinh ca ngi c bo him a ch ngi c bo him S chuyn nhng u i ng hng u i ng hng quyn u tin Notice Of Admission Flag Notice Of Admission Date Bo co ca nh du t cch Bo co ca ngy t cch M thng tin pht hnh Chng nhn s nhn trc (Pre-Admit Cert (PAC)) Ngy/Gi xc minh Xc minh bi Loi ca m tha thun Tnh trng ha n S ngy bo tn Ngy tr hon trc ngy tn ti M k hoch cng ty M s chnh sch Chnh sch c th khu tr Chnh sch gii hn lng Chnh sch gii hn ngy Gi tr phng bn c nhn

00442

18 19 20 21 22 23 24 25 26 27 28

26 106 2 2 2 1 8 1 8 2 15

TS XAD IS IS ST ID DT ID DT IS ST

O O O O O O O O O O O0093 0136 0136

00443

Y0135

00444

00445

0173

00446 00447

00448 00449 00450

00451

00452 00453

29 30 31 32 33 34 35 36 37 38 39 40

26 60 2 2 4 4 8 15 12 12 4 12

TS XCN IS IS NM NM IS ST CP CP NM CP

O O O O O O O O O B O B0042

00454

Y0098 0022

00455 00456 00457 00458 00459

00460 00461 00462

00463

00464

00465

SVTH: V THANH HONG

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SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM# 00466

ELEMENT NAME

41 42 43 44 45 46 47 48 49

12 60 1 106 2 8 3 2 12

CP CE IS XAD ST IS IS IS CX

B O O O O O O O O Y0072 0066

Gi tr phng c nhn Tnh trng lao ng ngi c hng bo him Gii tnh ngi c hng bo him a ch ngi ch ngi c hng bo him Tnh trng xc minh ID k hoch bo him trc Loi bao trm Kh khn M s ID ngi c hng bo him

00467

0001

00468

Y

00469

00470 00471

0309 0295

01227 00753 01230

2.4.7.0. Cc nh ngha trng IN1 2.4.7.1. ID k hoch bo him (Insurance Plan ID) (CE) 00368Thnh phn: ^ ^ ^ ^ ^

nh ngha: Trng ny cha nh danh duy nht cho k hoch bo him. Tham kho bng ngi dng nh ngha 0072 Insurance plan ID. loi tr mt k hoch, k hoch nn c gi vi gi tr null trong mi yu t con. Nu h thng tng ng c th h tr n, gi tr null c th c gi trong trng k hoch.2.4.7.2. ID cng ty bo him (Insurance company ID) (CX) 00428

nh ngha: Trng ny cha nh danh duy nht