ASTM E2017-1999(2010) 健康信息修订的标准指南

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【英文标准名称】:StandardGuideforAmendmentstoHealthInformation
【原文标准名称】:健康信息修订的标准指南
【标准号】:ASTME2017-1999(2010)
【标准状态】:现行
【国别】:美国
【发布日期】:1999
【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】:
【英文主题词】:confidentiality;healthcare;healthinformation;healthrecord;privacy;Amendments(tohealthinformation);Confidentiality;Electronichealthrecord(EHR);Healthknowledge/informationsystems;Patientbiographical/medicaldata;Privacy
【摘要】:Thepurposeofthisguideistoassurecomparabilitybetweenpaper-basedandcomputer-basedamendments.Paper-basedandcomputer-basedamendmentsmusthavecomparablemethods,practicesandpolicies,inordertoassureanunambiguousrepresentationofthesequenceandtimingofdocumentedevents.Originalandamendedhealthinformationentriesanddocumentsmustbothbedisplayedandmustbeconsistentacrossbothdomains.Comparabilitydoesnotruleout,however,theuseofcapabilitiesspecifictotheelectronicworld,whichdonothavepaper-basedcounterparts,forexample,displayingtheamendedtextwithapop-upwindow,whichcanshowthetextpriortoitsamendment.Traditionalpaper-basedhealthrecordsandpoliciessupporttheneedofauthorizedauthorsofhealthinformationtoamendentriesanddocumentsinthehealthrecordunderappropriatecircumstances.Inapaper-basedhealthrecord,amendingentriesisaccomplishedbydrawingalinethroughtheerroneousentry,writinginthecorrectinformation,andauthenticatingtheamendmentbysigninganddatingthechange.Suchcorrectionsalwaysdisplaytheoriginaldocumentationalongwiththeamendment.Thisprocedureisusedtoassureanunambiguousrepresentationofthesequenceandtimingofdocumentedeventsandanyappropriateamendments.Currentandemergingtechnologiesforhealthrecords,including,butnotlimitedto,computer-basedhealthrecords,employdifferentinputanddisplaymethodologiesthanthetraditionalpaper-basedrecordand,therefore,differentamendmentalternativesforhealthrecordorhealthinformationentries,orboth.Healthinformationmaybeentereddirectlyintoanautomated,electronic,orcomputer-basedhealthrecordsystem,forexample,byvoice,keyboard(eitherbythecarepractitioner,transcriptionist,orotherintermediary),mouse,pen,tablet,apersonaldigitalassistant,orthroughtheuseofstructureddataentry.Unlikeawrittenrecord,whichessentiallyisalwaysviewedinitsoriginalhandwrittenortypewrittenform,thepresentationanddisplayofelectronicandcomputer-basedhealthinformationoftenistransformed.Thistransformationoccurswheninformationistransferredfromonecomputerizedsystemtoanothersystemorfilteredbydifferentdisplaycharacteristicsorviewsofthedata.Inaddition,incontrasttothepaper-basedrecord,computersandcomputersystemscanmodifydisplayofthedatadirectly,forexample,innonchronologicalorderorfilteringthroughqueries.Amendedelectronicrecordsshoulddisplayadistinctandobviousnotationoftheiramendedstate.Accesstotheoriginalhealthinformationshouldbeimmediatelyavailable,thatis,prioramendmentsbacktoandincludingtheoriginalrecord.1.1Thisguideaddressesthecriteriaforamendingindividually-identifiablehealthinformation.Certaincriteriaforamendinghealthinformationisfoundinfederalandstatelaws,rulesandregulations,andinethicalstatementsofprofessionalconduct.Althoughthereareseveralsourcesforguidance,thereisnocurrentnationalstandardonthistopic.
【中国标准分类号】:C07
【国际标准分类号】:35_240_80
【页数】:5P.;A4
【正文语种】:英语