1、Designation:E236912An American National StandardStandard Specification forContinuity of Care Record(CCR)1This standard is issued under the fixed designation E2369;the number immediately following the designation indicates the year oforiginal adoption or,in the case of revision,the year of last revis
2、ion.A number in parentheses indicates the year of last reapproval.Asuperscript epsilon()indicates an editorial change since the last revision or reapproval.1.Scope1.1 The Continuity of Care Record(CCR)is a core data setof the most relevant administrative,demographic,and clinicalinformation facts abo
3、ut a patients healthcare,covering one ormore healthcare encounters.2It provides a means for onehealthcare practitioner,system,or setting to aggregate all of thepertinent data about a patient and forward it to anotherpractitioner,system,or setting to support the continuity of care.1.1.1 The CCR data
4、set includes a summary of the patientshealth status(for example,problems,medications,allergies)and basic information about insurance,advance directives,caredocumentation,and the patients care plan.It also includesidentifying information and the purpose of the CCR.(See 5.1for a description of the CCR
5、s components and sections,andAnnex A1 for the detailed data fields of the CCR.)1.1.2 The CCR may be prepared,displayed,and transmittedon paper or electronically,provided the information requiredby this specification is included.When prepared in a structuredelectronic format,strict adherence to an XM
6、L schema and anaccompanying implementation guide is required to supportstandards-compliant interoperability.The Adjunct3to thisspecification contains a W3C XML schema and Annex A2contains an Implementation Guide for such representation.1.2 The primary use case for the CCR is to provide asnapshotinti
7、mecontainingthepertinentclinical,demographic,and administrative data for a specific patient.1.2.1 This specification does not speak to other use cases orto workflows,but is intended to facilitate the implementationof use cases and workflows.Any examples offered in thisspecification are not to be con
8、sidered normative.41.3 To ensure interchangeability of electronic CCRs,thisspecification specifies XML coding that is required when theCCR is created in a structured electronic format.5This speci-fied XML coding provides flexibility that will allow users toprepare,transmit,and view the CCR in multip
9、le ways,forexample,in a browser,as an element in a Health Level 7(HL7)message or CDA compliant document,in a secure email,as aPDF file,as an HTML file,or as a word processing document.It will further permit users to display the fields of the CCR inmultiple formats.1.3.1 The CCR XMLschema or.xsd(see
10、theAdjunct to thisspecification)is defined as a data object that represents asnapshot of a patients relevant administrative,demographic,and clinical information at a specific moment in time.The CCRXML is not a persistent document,and it is not a messagingstandard.NOTE1The CCR XML schema can also be
11、used to define an XMLrepresentation for the CCR data elements,subject to the constraintsspecified in the accompanying Implementation Guide(see Annex A2).1.3.2 Using the required XML schema in theAdjunct to thisspecification or other XML schemas that may be authorizedthrough joints efforts of ASTM an
12、d other standards develop-ment organizations,properly designed electronic healthcarerecord(EHR)systems will be able to import and export allCCR data to enable automated healthcare information trans-mission with minimal workflow disruption for practitioners.Equally important,it will allow the interch
13、ange of the CCRdata between otherwise incompatible EHR systems.1.4 SecurityThe data contained within the CCR are pa-tient data and,if those data are identifiable,then end-to-endCCR document integrity and confidentiality must be provided1This specification is under the jurisdiction of ASTM Committee
14、E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data Management,Security,Confidentiality,and Privacy.Current edition approved Dec.1,2012.Published December 2012.Last previousversion published 2002 as E236905e2.DOI:10.1520/E2369-12.2A CCR is not inten
15、ded to be a medical-legal clinical or administrativedocument entered into a patients record,but may in specific use cases be used insuch a manner,provided that accepted policies and procedures in adding such datato a patients record are followed.A personal health record,with the informationunder the
16、 control of the patient or their designated representative,would be anexample of such a use case,as would be importation into an electronic health recordsystem,a data repository,or a registry.3Available from ASTM International Headquarters.Order Adjunct No.ADJE2369.Original adjunct produced in 2006.4Since the CCR is a core data set of selected,relevant information,it is not adischarge summary,that is,it does not include all of a patients health informationthat would be routinely recorded at the