ANSI/ASTM E1384-2007 电子健康记录(EHR)的内容和结构用实施规程
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【英文标准名称】:PracticeforContentandStructureoftheElectronicHealthRecord(EHR)
【原文标准名称】:电子健康记录(EHR)的内容和结构用实施规程
【标准号】:ANSI/ASTME1384-2007
【标准状态】:现行
【国别】:美国
【发布日期】:2007-10-23
【实施或试行日期】:2007-10-23
【发布单位】:美国国家标准学会(US-ANSI)
【起草单位】:ASTM
【标准类型】:()
【标准水平】:()
【中文主题词】:自动化;导则;图书馆学
【英文主题词】:Automation;Guidelines;Libraryscience
【摘要】:Thisguidecoversalltypesofhealthcareservices,includingthosegiveninacutecarehospitals,nursinghomes,skillednursingfacilities,homehealthcare,andspecialtycareenvironmentsaswellasambulatorycare.Theyapplybothtoshorttermcontacts(forexample,emergencyroomsandemergencymedicalserviceunits)andlongtermcontacts(primarycarephysicianswithlongtermpatients).Atthistime,thestandardvocabularyreflectsmoretraditionalcare.Asthestandardevolvesinthenextrevisions,thevocabularywillmoreadequatelyencompasstheentirecontinuumofcarethroughalldeliverymodels,healthstatusmeasurement,preventivecase,andhealtheducationcontent.Thisguidehasfivepurposes.ThefirstistoidentifythecontentandlogicalstructureofaElectronicHealthRecord(EHR).Therecordcarriesallhealthrelatedinformationaboutapatientovertime.Itincludessuchthingsasobservationsordescriptionsofthepatient(forexample,thephysiciansornursepractitionershistoryandphysical,laboratorytests,diagnosticimagingreports),providersordersforobservationsandtreatments,documentationabouttheactionscarriedout(forexample,therapiesordrugsadministered),patientidentifyinginformation,legalpermissions,andsoon.Thesecondgoalistodefinetherelationshipofdatacomingfromdiversesourcesystems(forexample,clinicallaboratoryinformationmanagementsystems,orderentrysystems,pharmacyinformationmanagementsystems,dictationsystems),andthedatastoredintheElectronicHealthRecord.RecallingthattheEHRistheprimaryrepositoryforinformationfromvarioussources,thestructureoftheEHRisreceptivetothedatathatflowfromothersystems.Third,inordertoacceleratetheadoptionofEHRs,thisguideprovidesacommonvocabulary,perspective,andreferencesforthosedeveloping,purchasing,andimplementingEHRsystems,butitdoesnotdealeitherwithimplementationorprocurement.Fourth,thisguidedescribesexamplesofavarietyofviewsbywhichthelogicaldatastructuremightbeaccessed/displayedinordertoaccomplishvariousfunctions.Fifth,thisguiderelatesthelogicalstructureoftheEHRtotheessentialdocumentationcurrentlyusedinthehealthcaredeliverysystemwithintheUnitedStatesinordertopromoteconsistencyandefficientdatatransfer.Itmapstotheclinicaldatacurrentlyinexistingdatasystemsandpatientcarerecords.
【中国标准分类号】:A14
【国际标准分类号】:01_140_20;35_240_30
【页数】:
【正文语种】:英语
【原文标准名称】:电子健康记录(EHR)的内容和结构用实施规程
【标准号】:ANSI/ASTME1384-2007
【标准状态】:现行
【国别】:美国
【发布日期】:2007-10-23
【实施或试行日期】:2007-10-23
【发布单位】:美国国家标准学会(US-ANSI)
【起草单位】:ASTM
【标准类型】:()
【标准水平】:()
【中文主题词】:自动化;导则;图书馆学
【英文主题词】:Automation;Guidelines;Libraryscience
【摘要】:Thisguidecoversalltypesofhealthcareservices,includingthosegiveninacutecarehospitals,nursinghomes,skillednursingfacilities,homehealthcare,andspecialtycareenvironmentsaswellasambulatorycare.Theyapplybothtoshorttermcontacts(forexample,emergencyroomsandemergencymedicalserviceunits)andlongtermcontacts(primarycarephysicianswithlongtermpatients).Atthistime,thestandardvocabularyreflectsmoretraditionalcare.Asthestandardevolvesinthenextrevisions,thevocabularywillmoreadequatelyencompasstheentirecontinuumofcarethroughalldeliverymodels,healthstatusmeasurement,preventivecase,andhealtheducationcontent.Thisguidehasfivepurposes.ThefirstistoidentifythecontentandlogicalstructureofaElectronicHealthRecord(EHR).Therecordcarriesallhealthrelatedinformationaboutapatientovertime.Itincludessuchthingsasobservationsordescriptionsofthepatient(forexample,thephysiciansornursepractitionershistoryandphysical,laboratorytests,diagnosticimagingreports),providersordersforobservationsandtreatments,documentationabouttheactionscarriedout(forexample,therapiesordrugsadministered),patientidentifyinginformation,legalpermissions,andsoon.Thesecondgoalistodefinetherelationshipofdatacomingfromdiversesourcesystems(forexample,clinicallaboratoryinformationmanagementsystems,orderentrysystems,pharmacyinformationmanagementsystems,dictationsystems),andthedatastoredintheElectronicHealthRecord.RecallingthattheEHRistheprimaryrepositoryforinformationfromvarioussources,thestructureoftheEHRisreceptivetothedatathatflowfromothersystems.Third,inordertoacceleratetheadoptionofEHRs,thisguideprovidesacommonvocabulary,perspective,andreferencesforthosedeveloping,purchasing,andimplementingEHRsystems,butitdoesnotdealeitherwithimplementationorprocurement.Fourth,thisguidedescribesexamplesofavarietyofviewsbywhichthelogicaldatastructuremightbeaccessed/displayedinordertoaccomplishvariousfunctions.Fifth,thisguiderelatesthelogicalstructureoftheEHRtotheessentialdocumentationcurrentlyusedinthehealthcaredeliverysystemwithintheUnitedStatesinordertopromoteconsistencyandefficientdatatransfer.Itmapstotheclinicaldatacurrentlyinexistingdatasystemsandpatientcarerecords.
【中国标准分类号】:A14
【国际标准分类号】:01_140_20;35_240_30
【页数】:
【正文语种】:英语
下载地址: 点击此处下载