【英文标准名称】:StandardSpecificationforContinuityofCareRecord(CCR)
【原文标准名称】:治疗记录连续性(CCR)的标准规范
【标准号】:ASTME2369-2005e1
【标准状态】:现行
【国别】:美国
【发布日期】:2005
【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】:(Specification)
【标准水平】:()
【中文主题词】:
【英文主题词】:actor;advancedirectives;adversereactions;alerts;allergies;attribute;caredocumentation;CCR;CCRBody;CCRcomponents;CCRFooter;CCRHeader;coding;comment;complexdatatypeorgroup;condition;ContinuityofCareRecord;coredataset;dataf
【摘要】:1.1TheContinuityofCareRecord(CCR)isacoredatasetofthemostrelevantadministrative,demographic,andclinicalinformationfactsaboutapatientx2019;shealthcare,coveringoneormorehealthcareencounters.Itprovidesameansforonehealthcarepractitioner,system,orsettingtoaggregateallofthepertinentdataaboutapatientandforwardittoanotherpractitioner,system,orsettingtosupportthecontinuityofcare.1.1.1TheCCRdatasetincludesasummaryofthepatientx2019;shealthstatus(forexample,problems,medications,allergies)andbasicinformationaboutinsurance,advancedirectives,caredocumentation,andthepatientx2019;scareplan.ItalsoincludesidentifyinginformationandthepurposeoftheCCR.(See5.1foradescriptionoftheCCRx2019;scomponentsandsections,andAnnexA1forthedetaileddatafieldsoftheCCR.)1.1.2TheCCRmaybeprepared,displayed,andtransmittedonpaperorelectronically,providedtheinformationrequiredbythisspecificationisincluded.Whenpreparedinastructuredelectronicformat,strictadherencetoanXMLschemaandanaccompanyingimplementationguideisrequiredtosupportstandards-compliantinteroperability.TheAdjuncttothisspecificationcontainsaW3CXMLschemaandAnnexA2containsanImplementationGuideforsuchrepresentation.1.2TheprimaryusecasefortheCCRistoprovideasnapshotintimecontainingthepertinentclinical,demographic,andadministrativedataforaspecificpatient.1.2.1Thisspecificationdoesnotspeaktootherusecasesortoworkflows,butisintendedtofacilitatetheimplementationofusecasesandworkflows.Anyexamplesofferedinthisspecificationarenottobeconsiderednormative.1.3ToensureinterchangeabilityofelectronicCCRs,thisspecificationspecifiesXMLcodingnbsp;nbsp;nbsp;thatisrequiredwhentheCCRiscreatedinastructuredelectronicformat.ThisspecifiedXMLcodingprovidesflexibilitythatwillallowuserstoprepare,transmit,andviewtheCCRinmultipleways,forexample,inabrowser,asanelementinaHealthLevel7(HL7)messageorCDAcompliantdocument,inasecureemail,asaPDFfile,asanHTMLfile,orasawordprocessingdocument.ItwillfurtherpermituserstodisplaythefieldsoftheCCRinmultipleformats.1.3.1TheCCRXMLschemaor.xsd(seetheAdjuncttothisspecification)isdefinedasadataobjectthatrepresentsasnapshotofapatientx2019;srelevantadministrative,demographic,andclinicalinformationataspecificmomentintime.TheCCRXMLisnotapersistentdocument,anditisnotamessagingstandard.Note18212;TheCCRXMLschemacanalsobeusedtodefineanXMLrepresentationfortheCCRdataelements,subjecttotheconstraintsspecifiedintheaccompanyingImplementationGuide(seeAnnexA2).1.3.2UsingtherequiredXMLschemaintheAdjuncttothisspecificationorotherXMLschemasthatmaybeauthorizedthroughjointseffortsofASTMandotherstandardsdevelopmentorganizations,properlydesignedelectronichealthcarerecord(EHR)systemswillbeabletoimportandexportallCCRdatatoenableautomatedhealthcareinformationtransmissionwithminimalworkflowdisruptionforpractitioners.Equallyimportant,itwillallowtheinterchangeoftheCCRdatabetweenotherwiseincompatibleEHRsystems.1.4Security8212;ThedatacontainedwithintheCCRarepatientdataand,ifthosedataarenbsp;nbsp;nbsp;identifiable,thenend-to-endCCRdocumentintegrity......
【中国标准分类号】:C07
【国际标准分类号】:35_240_80
【页数】:100P.;A4
【正文语种】:英语