卫生部医疗记录标准

序号一级类目二级类目三级类目基本活动名称卫生服务活动标识符1.基本信息个人信息建档注册A0001.01012.维护A0001.01023.卫生服务人员注册A0002.01014.维护A0002.01025.卫生服务机构建档注册A0003.01016.维护A0003.01027.公共卫生儿童保健出生医学证明事件报告B0101.07028.新生儿访视专案登记B0102.02049.随访记录B0102.051010.新生儿疾病筛查专案登记B0103.020411.实验室检验记录B0103.030312.诊断记录B0103.040113.儿童健康体检专案登记B0104.020414.问询记录B0104.030115.实验室检验记录B0104.030216.体格检查记录B0104.030317.医学指导B0104.051118.评估报告B0104.060119.体弱儿童管理专案登记B0105.020420.问询记录B0105.030121.体格检查记录B0105.030222.影像检查记录B0105.030523.实验室检验记录B0105.030324.医学指导B0105.051125.评估报告B0105.060126.妇女保健婚前保健服务问询记录B0201.030127.医学指导B0201.051128.体格检查记录B0201.030229.影像检查记录B0201.030530.实验室检验记录B0201.030331.诊断记录B0201.040132.转诊记录B0201.020333.妇女病普查问询记录B0202.030134.体格检查记录B0202.030235.影像检查记录B0202.030536.实验室检验记录B0202.030337.医学指导B0202.051138.计划生育技术服务问询记录B0203.030139.体格检查记录B0203.030240.影像检查记录B0203.030541.实验室检验记录B0203.030342.诊断记录B0203.040143.手术记录B0203.050344.医学指导B0203.051145.产前保健专案登记B0204.020446.问询记录B0204.030147.体格检查记录B0204.030248.影像检查记录B0204.030549.实验室检验记录B0204.030350.医学指导B0204.051151.转诊记录B0204.020352.产时保健分娩记录B0205.050853.产后保健专案登记B0206.020454.随访记录B0206.051055.体格检查记录B0206.030256.实验室检验记录B0206.030357.医学指导B0206.051158.评估报告B0206.060159.高危孕产妇管理专案登记B0207.020460.问询记录B0207.030161.体格检查记录B0207.030262.影像检查记录B0207.030563.实验室检验记录B0207.030364.医学指导B0207.051165.评估报告B0207.060166.产前筛查专案登记B0208.020467.问询记录B0208.030168.体格检查记录B0208.030269.影像检查记录B0208.030570.实验室检验记录B0208.030371.产前诊断专案登记B0209.020472.问询记录B0209.030173.体格检查记录B0209.030274.影像检查记录B0209.030575.实验室检验记录B0209.030376.医学指导B0209.051177.诊断记录B0209.040178.出生缺陷监测疾病报告B0210.070179.疾病控制预防接种预防接种记录B0301.050180.传染病报告疾病报告B0302.070181.结核病防治疾病报告B0303.070182.随访记录B0303.051083.医学指导B0303.051184.问询记录B0303.030185.用药记录B0303.050286.体格检查记录B0303.030287.实验室检验记录B0303.030388.物理检查记录B0303.030489.影像检查记录B0303.030590.诊断记录B0303.040191.手术记录B0303.050392.转诊记录B0303.020393.费用结算B0303.080194.评估报告B0303.060195.艾滋病防治疾病报告B0304.070196.问询记录B0304.030197.用药记录B0304.050298.体格检查记录B0304.030299.实验室检验记录B0304.0303100.物理检查记录B0304.0304101.影像检查记录B0304.0305102.诊断记录B0304.0401103.输血记录B0304.0509104.转诊记录B0304.0203105.费用记录B0304.0801106.血吸虫病防治疾病报告B0305.0701107.随访记录B0305.0510108.诊断记录B0305.0401109.医学指导B0305.0511110.问询记录B0305.0301111.用药记录B0305.0502112.体格检查记录B0305.0302113.实验室检验记录B0305.0303114.物理检查记录B0305.0304115.影像检查记录B0305.0305116.手术记录B0305.0503117.转诊记录B0305.0203118.费用结算B0305.0801119.评估报告B0305.0601120.慢性丝虫病病人管理疾病报告B0306.0701121.随访记录B0306.0401122.诊断记录B0306.0510123.医学指导B0306.0511124.问询记录B0306.0301125.用药记录B0306.0502126.体格检查记录B0306.0302127.实验室检验记录B0306.0303128.物理检查记录B0306.0304129.影像检查记录B0306.0305130.手术记录B0306.0503131.转诊记录B0306.0203132.费用结算B0306.0801133.评估报告B0306.0601134.职业病报告疾病报告B0307.0701135.职业性健康监护体检登记B0308.0202136.体格检查记录B0308.0302137.诊断记录B0308.0401138.实验室检验记录B0308.0303139.物理检查记录B0308.0304140.影像检查记录B0308.0305141.费用结算B0308.0601142.评估报告B0308.0801143.伤害监测报告事件报告B0309.0702144.中毒报告事件报告B0310.0702145.行为危险因素监测问询记录B0311.0301146.评估报告B0311.0601147.死亡医学证明事件报告B0312.0702148.疾病管理高血压病例管理转诊记录B0401.0203149.专案记录B0401.0204150.问询记录B0401.0301151.体格检查记录B0401.0302152.物理检查记录B0401.0304153.影像检查记录B0401.0305154.实验室检验记录B0401.0303155.用药记录B0401.0502156.其他治疗记录B0401.0599157.随访记录B0401.0510158.医学指导B0401.0511159.评估报告B0401.0601160.诊断记录B0401.0401161.费用结算B0401.0801162.糖尿病病例管理转诊记录B0402.0203163.专案记录B0402.0204164.问询记录B0402.0301165.体格检查记录B0402.0302166.物理检查记录B0402.0304167.影像检查记录B0402.0305168.实验室检验记录B0402.0303169.用药记录B0402.0502170.其他治疗记录B0402.0599171.随访记录B0402.0510172.医学指导B0402.0511173.评估报告B0402.0601174.诊断记录B0402.0401175.费用结算B0402.0801176.肿瘤病例管理转诊记录B0403.0203177.专案记录B0403.0204178.问询记录B0403.0301179.体格检查记录B0403.0302180.物理检查记录B0403.0304181.影像检查记录B0403.0305182.实验室检验记录B0403.0303183.用药记录B0403.0502184.放射治疗记录B0403.0505185.手术记录B0403.0503186.麻醉记录B0403.0504187.其他治疗记录B0403.0599188.随访记录B0403.0510189.医学指导B0403.0511190.评估报告B0403.0601191.诊断记录B0403.0401192.疾病报告B0403.0701193.费用结算B0403.0801194.精神分裂症病历管理转诊记录B0404.0203195.专案记录B0404.0204196.问询记录B0404.0301197.体格检查记录B0404.0302198.物理检查记录B0404.0304199.影像检查记录B0404.0305200.实验室检验记录B0404.0303201.用药记录B0404.0502202.其他治疗记录B0404.0599203.随访记录B0404.0510204.医学指导B0404.0511205.评估报告B0404.0601206.诊断记录B0404.0401207.费用结算B0404.0801208.老年人健康管理专案记录B0405.0204209.问询记录B0405.0301210.体格检查记录B0405.0302211.物理检查记录B0405.0304212.实验室检验记录B0405.0303213.用药记录B0405.0502214.其他治疗记录B0405.0599215.随访记录B0405.0510216.医学指导B0405.0511217.评估报告B0405.0601218.诊断记录B0405.0401219.费用结算B0405.0801220.医疗服务门诊诊疗临床服务登记C0001.0201221.问询记录C0001.0301222.用药记录C0001.0502223.体格检查记录C0001.0302224.实验室检验记录C0001.0303225.物理检查记录C0001.0304226.影像检查记录C0001.0305227.诊断记录C0001.0401228.手术记录C0001.0503229.麻醉记录C0001.0504230.放射治疗记录C0001.0505231.介入治疗记录C0001.0506232.植入治疗记录C0001.0507233.输血记录C0001.0509234.其他治疗记录C0001.0599235.转诊记录C0001.0203236.费用结算C0001.0801237.住院诊疗临床服务登记C0002.0201238.问询记录C0002.0301239.用药记录C0002.0502240.体格检查记录C0002.0302241.实验室检验记录C0002.0303242.物理检查记录C0002.0304243.影像检查记录C0002.0305244.诊断记录C0002.0401245.手术记录C0002.0503246.麻醉记录C0002.0504247.放射治疗记录C0002.0505248.介入治疗记录C0002.0506249.植入治疗记录C0002.0507250.输血记录C0002.0509251.其他治疗记录C0002.0599252.评估报告C0002.0601253.转诊记录C0002.0203254.费用结算C0002.0801255.住院病案首页评估报告C0003.0601256.健康体检体检登记C0004.0202257.体检检查记录C0004.0302