ASTM E1744-2004(2010) 电子健康记录中急症治疗观测的标准实施规程

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【英文标准名称】:StandardPracticeforViewofEmergencyMedicalCareintheElectronicHealthRecord
【原文标准名称】:电子健康记录中急症治疗观测的标准实施规程
【标准号】:ASTME1744-2004(2010)
【标准状态】:现行
【国别】:美国
【发布日期】:2004
【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】:(Practice)
【标准水平】:()
【中文主题词】:
【英文主题词】:computer-basedpatientrecord;emergencydepartmentdataset;emergencymedicalcare;inpatientdataset;pre-hospitalEMSdataset;Computer-basedpatientrecord(CPR);Dataanalysis--medicalapplications;Emergencymedicalservices(EMS);Patientbiogr
【摘要】:TheEmergencyMedicalServiceSystem(EMSS)intheUnitedStateshaslargelyarisensince1945andhasdrawntoagreatdegreefromtheexperiencegainedinmilitaryconflictsduringandsinceWorldWarII.Thedocumentationofcare,however,hasremainedlargelypaperrecordx2013;baseduntilrecently.Beginninginthe1970sbothcivilianandmilitaryagencieshavecloselyexaminedelectronicmeansofstoringandmanagingpatientdataaboutemergencymedicalcare.ThereportoftheInstituteofMedicineontheComputer-BasedPatientRecordhasemphasizedtheuseofinformationtechnologyinpatientcareingeneralandemergencycaredatainparticular.DuringthisperiodASTMhasdocumentedthelogicalstructureoftheelectronichealthrecordinGuideE1239andPracticeE1384,whileGuidesF1288andF1629hasdefinedthepatientcaredata,tobegatheredinthepre-hospitalrecord,andtheoutcomedata,relativetothepre-hospitalphaseoftheemergency,whicharecollectedintheemergencydepartmentandafterinpatientadmission.SpecificationsforthelogicalmodelarealsopresentedinPracticeE1715.ThispracticeshowshowthedatagatheredforEMSoperationsandmanagementmergesmoothlyintothecomputer-basedpatientrecord,consistentwiththerecognitionthatthesedataarepartoftheprimaryrecordofcare.Severalstateshaveformalizedthatrecognitioninstatelaw.Thispracticedoesnotinstructphysicianshowtocollectdataforpatientcare.Thispracticedoesnotindicatewhatinformationneedstobecollectedatthetimeofpatientcare.Thetasknowistodocument,usingstandardconventions,themeansbywhichthisintegrationoccursinordertosetthestageforthecaptureandtransferofsuchemergencycaredatausinginformationtechnologyandtelecommunicationsinastandardizedwayconsistentwithallothersettingsofcarewhileprotectingtheprivacyandconfidentialityofthatdata.TheelectronichealthrecordhasthepotentialtoreducehealthcarecostsbyoptimizingcasemanagementandsupportingeffectivepostEDfollow-up.Systematizingthedataalsoenhancesitsabilitytobeusedconsistently,withproperprotection,forresearchintoandformanagementofEMSSoperationswithinthevariousjurisdictionalboundaries.Theelectronicformoftheemergencyepisodedocumentationutilizesthesamelogicaldatamodelastheelectronichealthrecord,butitfocusesondatacollectedduringthedifferentphasesoftheemergency.Thesedatasetsdonotlimitwhatmayberecorded,orbywhom,buttheydoidentifythosedataconsideredessential,whentheyexist.Thesedatasetsincludeallthosedatarecordedtodocumentinstancesofemergencymedicalcare.Dataorganizedtoenhanceflexibleandefficientmanagementofinformation.Identificationsofpractitionersandfacilitieswillbecoded,whennecessary,toprotectconfidentialityandtomakeproviderdatacomparable.Nameswillbeincludedwhentheyarenecessarytosupportpatientcare.PrivacyandconfidentialityofpatientdatashouldbehandledaccordingtoGuideE1869.Provideridentificationnumberswillbemaintainedonmasterdatafileswhichalsoincludeadditionalinformationsuchasspecialty,licenselevel,andthelike.......
【中国标准分类号】:C07
【国际标准分类号】:35_240_80
【页数】:27P.;A4
【正文语种】:英语