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- <?xml version="1.0" encoding="euc-kr"?>
- <?xml-stylesheet type="text/xsl" href="SMMNW04000_중증도.xsl"?>
- <SignData>
- <PatientInfo name="환자정보">
- <pid name="환자번호">17616976</pid>
- <pname name="환자이름">임문영</pname>
- <age name="나이성별">M/60</age>
- <btype name="혈액형">A+</btype>
- <insukind name="보험유형">건강보험</insukind>
- <orddept name="진료과">신경외과</orddept>
- <apntdr name="지정의">전신수</apntdr>
- <attndr name="주치의">박흥식</attndr>
- </PatientInfo>
- <SignInfo name="인증정보">
- <sing>
- <redord>
- <clsflag>일반병동</clsflag>
- <usernm>ENR사용자</usernm>
- <execdt>20071214</execdt>
- <exectm>1642</exectm>
- </redord>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000001</grupcd>
- <hngnm>
- <![CDATA[위생관리]]>
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- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
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- <hngnm>
- <![CDATA[스스로 위생관리 가능(구강간호/목욕/배설)]]>
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- <refseq>1</refseq>
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- <grupmulti>1</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
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- <sortseq>1</sortseq>
- <basepnt>1</basepnt>
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- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000006</grupcd>
- <hngnm>
- <![CDATA[영양]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
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- <cnfmyn>Y</cnfmyn>
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- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000008</grupcd>
- <hngnm>
- <![CDATA[식사 준비 등 부분적 도움]]>
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- <supcd>00000006</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
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- <grupmulti>2</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>2</sortseq>
- <basepnt>2</basepnt>
- <rgstseq>00002339</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000011</grupcd>
- <hngnm>
- <![CDATA[배설]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000012</grupcd>
- <hngnm>
- <![CDATA[스스로 배변, 배뇨 가능]]>
- </hngnm>
- <refseq>1</refseq>
- <supcd>00000011</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>1</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>1</sortseq>
- <basepnt>1</basepnt>
- <rgstseq>00002340</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000016</grupcd>
- <hngnm>
- <![CDATA[운동 및 활동]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000019</grupcd>
- <hngnm>
- <![CDATA[침상 내에서 부분적 도움으로 수동적 운동]]>
- </hngnm>
- <refseq>3</refseq>
- <supcd>00000016</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>3</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>3</sortseq>
- <basepnt>3</basepnt>
- <rgstseq>00002341</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000021</grupcd>
- <hngnm>
- <![CDATA[교육 및 자문]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000023</grupcd>
- <hngnm>
- <![CDATA[처치에 대한 설명과 교육이 요구됨]]>
- </hngnm>
- <refseq>2</refseq>
- <supcd>00000021</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>2</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>2</sortseq>
- <basepnt>2</basepnt>
- <rgstseq>00002342</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000026</grupcd>
- <hngnm>
- <![CDATA[정서적 지지]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000029</grupcd>
- <hngnm>
- <![CDATA[우울이나 분노가 자주 관찰]]>
- </hngnm>
- <refseq>3</refseq>
- <supcd>00000026</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>3</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>3</sortseq>
- <basepnt>3</basepnt>
- <rgstseq>00002343</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000031</grupcd>
- <hngnm>
- <![CDATA[의사소통 및 의식상태]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000032</grupcd>
- <hngnm>
- <![CDATA[지남력이 명확하고 의사소통 명확함]]>
- </hngnm>
- <refseq>1</refseq>
- <supcd>00000031</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>1</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>1</sortseq>
- <basepnt>1</basepnt>
- <rgstseq>00002344</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000036</grupcd>
- <hngnm>
- <![CDATA[치료 및 검사]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000038</grupcd>
- <hngnm>
- <![CDATA[검사 및 치료 전후 약간의 준비와 설명이 필요]]>
- </hngnm>
- <refseq>2</refseq>
- <supcd>00000036</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>2</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>2</sortseq>
- <basepnt>2</basepnt>
- <rgstseq>00002345</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000041</grupcd>
- <hngnm>
- <![CDATA[투약]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000043</grupcd>
- <hngnm>
- <![CDATA[3회/1일 이상의 투약 및 관찰이 필요]]>
- </hngnm>
- <refseq>2</refseq>
- <supcd>00000041</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>2</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>2</sortseq>
- <basepnt>2</basepnt>
- <rgstseq>00002346</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000046</grupcd>
- <hngnm>
- <![CDATA[측정 및 관찰]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000047</grupcd>
- <hngnm>
- <![CDATA[기본적인 활력증후 측정]]>
- </hngnm>
- <refseq>1</refseq>
- <supcd>00000046</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>1</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>1</sortseq>
- <basepnt>1</basepnt>
- <rgstseq>00002347</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000051</grupcd>
- <hngnm>
- <![CDATA[환자관리를 위한 부서간 조정]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000055</grupcd>
- <hngnm>
- <![CDATA[잦은 타과의뢰, 치료사 및 사회복지사 등과 환자관리 논의 많음]]>
- </hngnm>
- <refseq>4</refseq>
- <supcd>00000051</supcd>
- <todd>99991231</todd>
- <depth>2</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptyn>1</timsinptyn>
- <timsinptynflag>1</timsinptynflag>
- <grupmulti>4</grupmulti>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>4</sortseq>
- <basepnt>4</basepnt>
- <rgstseq>00002348</rgstseq>
- </histgrup>
- <histgrup>
- <stat>-</stat>
- <flag>N</flag>
- <grupcd>00000056</grupcd>
- <hngnm>
- <![CDATA[퇴원 및 전동관리]]>
- </hngnm>
- <refseq>0</refseq>
- <supcd>00000000</supcd>
- <todd>99991231</todd>
- <depth>1</depth>
- <grupflag>1</grupflag>
- <clsflag>1</clsflag>
- <recflag>1</recflag>
- <cnfmyn>Y</cnfmyn>
- <timsinptynflag>1</timsinptynflag>
- <cmtinptyn>Y</cmtinptyn>
- <inptchkflag>Y</inptchkflag>
- <fromdd>20070521</fromdd>
- <sortseq>0</sortseq>
- </histgrup>
- <histgrup>
- <stat>I</stat>
- <flag>Y</flag>
- <grupcd>00000060</grupcd>
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- <![CDATA[상태 악화로 중환자실 이동 시 환자 및 보호자 관리]]>
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