1.標(biāo)識(shí)(Identification) 2.人口學(xué)及社會(huì)經(jīng)濟(jì)學(xué)特征(Demographics and social economics characteristics) 3.健康史(Health history) 4.主訴與癥狀(Chief complaint and symptom) 5.體格檢查(Physical examination) 6.臨床輔助檢查(Assistant examination) 7.實(shí)驗(yàn)室檢查(Laboratory examination) 8.醫(yī)學(xué)診斷(Diagnosis) 9.醫(yī)學(xué)評(píng)估(Medical assessment) 10.計(jì)劃與干預(yù)(Medical plan and intervention) 11.衛(wèi)生費(fèi)用(Healthcare expenditure) 12.衛(wèi)生機(jī)構(gòu)(Healthcare organization) 13.?dāng)?shù)據(jù)元值域代碼表(Data element range code table) 參考文獻(xiàn)