Standards for the content of the electronic health record.
Standards for the content of the electronic health record.
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发表时间：
2002-09
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通讯作者：
V. Watzlaf;Xiaoming Zeng;C. Jarymowycz;Patti Firouzan
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作者：
V. Watzlaf;Xiaoming Zeng;C. Jarymowycz;Patti Firouzan
进行了一项描述性横断面研究，以测量美国材料测试协会（ASTM）关于电子健康记录内容和结构的标准中推荐的最低内容的认识、使用和有效性。开发了一项基于网络的调查，并将其用作收集这些数据的主要工具。数据是从全国各地的医疗机构、供应商和志愿者的随机样本中收集的。13%的受访者拥有电子健康记录（EHR）系统，而10%的受访者没有或不打算拥有电子健康记录系统。大多数受访者（62%）使用供应商系统进行电子病历开发。大多数受访者不知道或稍微知道ASTM E1384标准。受访者认为，ASTM标准中列出的最低数据元素应包括在所有EHR系统中。诸如教育水平、与处置相关的患者指示、问题编号、治疗计划ID、提供者代理ID代码和最后一次补充用药日期等数据项不应总是包含在EHR系统中。
A descriptive, cross-sectional study was performed to measure the awareness, use, and validity of the minimum content recommended in the American Society for Testing and Materials (ASTM) standards for content and structure of electronic health records. A Web-based survey was developed and used as the primary tool to collect this data. Data was collected from a random sample of healthcare facilities from across the country, vendors, and volunteers. Thirteen percent of respondents had an electronic health record (EHR) system fully in place while 10 percent did not have or did not plan to have an EHR system. The majority of respondents (62 percent) used a vendor system for EHR development. The majority of respondents were not aware or slightly aware of the ASTM E1384 standards. Respondents believed that the minimum data elements outlined in the ASTM standards should be included in all EHR systems. Data items such as educational level, patient instructions related to disposition, problem numbers, treatment plan ID, provider agency ID code, and medication date of last refill should not always be included in EHR systems.