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[1] [2] [3] All certified Electronic health records in the United States are required to export medical data using the C-CDA standard. [4] While the standard was developed primarily for the United States as the C-CDA incorporates references to terminologies and value set required by US regulation, it has also been used internationally.
Barcode technology can help prevent medical errors by making accurate and reliable information readily available at the point-of-care. Information, such as the drug identification, medication management, infusion safety, specimen collection, etc. and any other patient care activity can be easily tracked during the patient stay.
HL7 and DICOM manage a joint Working Group to harmonize areas where the two standards overlap and address imaging integration in the electronic medical record. Integrating the Healthcare Enterprise (IHE) is an industry sponsored non-profit organization that profiles the use of standards to address specific healthcare use cases. DICOM is ...
In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTM's Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards. [citation needed]
The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States , with more than 80% of hospitals adopting some form of EHR system ...
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
Health Level Seven, abbreviated to HL7, is a range of global standards for the transfer of clinical and administrative health data between applications with the aim to improve patient outcomes and health system performance. The HL7 standards focus on the application layer, which is "layer 7" in the Open Systems Interconnection model.
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