ANSI/ASTM E2369-2005 护理记录的连续性规范(CCR)

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【英文标准名称】:SpecificationfortheContinuityofCareRecord(CCR)
【原文标准名称】:护理记录的连续性规范(CCR)
【标准号】:ANSI/ASTME2369-2005
【标准状态】:现行
【国别】:美国
【发布日期】:
【实施或试行日期】:
【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】:护理;连续性;纪录
【英文主题词】:Care;Continuity;Record
【摘要】:TheContinuityofCareRecord(CCR)isacoredatasetofthemostrelevantadministrative,demographic,andclinicalinformationfactsaboutapatientshealthcare,coveringoneormorehealthcareencounters.Itprovidesameansforonehealthcarepractitioner,system,orsettingtoaggregateallofthepertinentdataaboutapatientandforwardittoanotherpractitioner,system,orsettingtosupportthecontinuityofcare.TheCCRdatasetincludesasummaryofthepatientshealthstatus(forexample,problems,medications,allergies)andbasicinformationaboutinsurance,advancedirectives,caredocumentation,andthepatientscareplan.ItalsoincludesidentifyinginformationandthepurposeoftheCCR.(See5.1foradescriptionoftheCCRscomponentsandsections,andAnnexA1forthedetaileddatafieldsoftheCCR.)TheCCRmaybeprepared,displayed,andtransmittedonpaperorelectronically,providedtheinformationrequiredbythisspecificationisincluded.Whenpreparedinastructuredelectronicformat,strictadherencetoanXMLschemaandanaccompanyingimplementationguideisrequiredtosupportstandards-compliantinteroperability.TheAdjuncttothisspecificationcontainsaW3CXMLschemaandcontainsanImplementationGuideforsuchrepresentation.TheprimaryusecasefortheCCRistoprovideasnapshotintimecontainingthepertinentclinical,demographic,andadministrativedataforaspecificpatient.Thisspecificationdoesnotspeaktootherusecasesortoworkflows,butisintendedtofacilitatetheimplementationofusecasesandworkflows.Anyexamplesofferedinthisspecificationarenottobeconsiderednormative.ToensureinterchangeabilityofelectronicCCRs,thisspecificationspecifiesXMLcodingthatisrequiredwhentheCCRiscreatedinastructuredelectronicformat.ThisspecifiedXMLcodingprovidesflexibilitythatwillallowuserstoprepare,transmit,andviewtheCCRinmultipleways,forexample,inabrowser,asanelementinaHealthLevel7(HL7)messageorCDAcompliantdocument,inasecureemail,asaPDFfile,asanHTMLfile,orasawordprocessingdocument.ItwillfurtherpermituserstodisplaythefieldsoftheCCRinmultipleformats.TheCCRXMLschemaor.xsd(seetheAdjuncttothisspecification)isdefinedasadataobjectthatrepresentsasnapshotofapatientsrelevantadministrative,demographic,andclinicalinformationataspecificmomentintime.TheCCRXMLisnotapersistentdocument,anditisnotamessagingstandard.Note1-TheCCRXMLschemacanalsobeusedtodefineanXMLrepresentationfortheCCRdataelements,subjecttotheconstraintsspecifiedintheaccompanyingImplementationGuide(seeAnnexA2).UsingtherequiredXMLschemaintheAdjuncttothisspecificationorotherXMLschemasthatmaybeauthorizedthroughjointseffortsofASTMandotherstandardsdevelopmentorganizations,properlydesignedelectronichealthcarerecord(EHR)systemswillbeabletoimportandexportallCCRdatatoenableautomatedhealthcareinformationtransmissionwithminimalworkflowdisruptionforpractitioners.Equallyimportant,itwillallowtheinterchangeoftheCCRdatabetweenotherwiseincompatibleEHRsystems.
【中国标准分类号】:C07
【国际标准分类号】:35_240_80
【页数】:
【正文语种】:英语