【英文标准名称】:StandardPracticeforContentandStructureoftheElectronicHealthRecord(EHR)
【原文标准名称】:电子健康记录(EHR)的内容和结构用标准实施规程
【标准号】:ASTME1384-2007
【标准状态】:现行
【国别】:
【发布日期】:2007
【实施或试行日期】:
【发布单位】:美国材料与试验协会(US-ASTM)
【起草单位】:E31.25
【标准类型】:(Guide)
【标准水平】:()
【中文主题词】:自动化;指南;信息处理;图书馆学
【英文主题词】:datatype;dataviews;EHRprinciples;electronichealthrecord;mastertable;objects;segments
【摘要】:1.1Thispracticecoversalltypesofhealthcareservices,includingthosegiveninambulatorycare,hospitals,nursinghomes,skillednursingfacilities,homehealthcare,andspecialtycareenvironments.Theyapplybothtoshorttermcontacts(forexample,emergencyroomsandemergencymedicalserviceunits)andlongtermcontacts(primarycarephysicianswithlongtermpatients).Thevocabularyaimstoencompassthecontinuumofcarethroughalldeliverymodels.ThispracticedefinesthepersistentdataneededtosupportElectronicHealthRecordsystemfunctionality.1.2Thispracticehasfourpurposes:1.2.1IdentifythecontentandlogicaldatastructureandorganizationofanElectronicHealthRecord(EHR)consistentwithcurrentlyacknowledgedpatientrecordcontent.Therecordcarriesallhealthrelatedinformationaboutapersonovertime.Itmayincludehistoryandphysical,laboratorytests,diagnosticreports,ordersandtreatmentsdocumentation,patientidentifyinginformation,legalpermissions,andsoon.Thecontentispresentedanddescribedasdataelementsorasclinicaldocuments.ThisstandardisconsistentwitheXtensibleMarkupLanguage(XML).SeeDocumentTypeDefinition(DTD)2.1andW3CXMLSchema1.01.2.2Explaintherelationshipofdatacomingfromdiversesources(forexample,clinicallaboratoryinformationmanagementsystems,orderentrysystems,pharmacyinformationmanagementsystems,dictationsystems),andotherdataintheElectronicHealthRecordastheprimaryrepositoryforinformationfromvarioussources.1.2.3Provideacommonvocabularyforthosedeveloping,purchasing,andimplementingEHRsystems.1.2.4Providesufficientcontentfromwhichdataextractscanbecompiledtocreateuniquesetting"views."1.2.5Mapthecontenttoselectedrelevantbiomedicalandhealthinformaticsstandards.
【中国标准分类号】:A14
【国际标准分类号】:01_140_20;35_240_30
【页数】:127P.;A4
【正文语种】: