美国国家标准与技术研究院(National Institute of Standards and Technology,NIST )对电子病历的认证 分几个阶段,每个阶段又分门诊和住院,然后又分若干模块。下面是疾病列表的测试脚本。
170.302c_Problemlist
Test user and data:
User Password user type
D003 123456 Doctor
Patient:McSorley John
Notes:
Steps:
- Electronically Record Patient Medication Problem List
- 以医生D003登陆系统,在 "Track Patients" 中选择病人McSorley John, 点击Patient Chart:
- 在此界面点击Visits菜单,选择在Allergy list中添加的那条Visits记录,点击Edit Visit按钮,进入visit详细信息界面:
选择Diagnosis菜单,会出现病人problem界面,此页面分为两个上下两部分:上面Diagnosis for visit是本次visit的确诊的problems,下面Problems为病人历次Visits时的诊断problem。
点击Diagnosis for visit下的add按钮,可以进入病人Problem添加页面:
在病人添加页面,点击Code后面的放大镜,会弹出病的选择界面,选择SNOMED CT的编码,在Code中输入病的SNOMED CT,点击Search即可进行查询,查询出来后点击ok按钮,病的名称即可选择成功,如上图所示,
然后在添加病人Problem页面依次填写status, certainty, severity,等信息,将如下的problem记录录入进去:
其中测试日期2月前和1月前的两个 problem 记录会由脚本自动生成: Today 的 problem 添加如下两图所示:
- Enter For Visit #1 -- 2 Months Before Test Date
- Recurrent Urinary Tract Infection, Status: Active
- ICD-9 Code: V13.02
- SNOMED CT Code: 197927001
- Recurrent Urinary Tract Infection, Status: Active
- Enter For Visit #2 -- 1 Month Before Test Date
- Essential Hypertension, Status: Active
- ICD-9 Code: 401.9
- SNOMED CT Code: 59621000
- Essential Hypertension, Status: Active
- Enter For Visit #3 -- Today
- Cerebrovascular Accident, Status: Active
- ICD-9 Code: V12.54
- SNOMED CT Code: 230690007
- Chronic Obstructive Pulmonary Disease, Status: Active
- ICD-9 Code: 496
- SNOMED CT Code: 13645005
- Cerebrovascular Accident, Status: Active
- 上面的Problem数据全部输入完成后,界面如下图所示:
- Electronically Modify Patient Medication Problem List
- 选择SNOMED CT Code为 197927001 的problem记录,点击按钮"Edit",将此记录中的status改为"Resolved",如下图所示:
- 选择SNOMED CT Code为59621000 的problem记录,点击"Edit",将记录的status改为"Inactive":
- Electronically Retrieve Patient Problem List and Problem List History in an Ambulatory Setting
- 医生D003重新登录后,进入该病人patient chart下的visit,查看其Diagnosis页面下方Problem页签中,在Status处选择Active,然后点击Search按钮,Active状态的Problem会被查询出来,界面如下图所示:
- 在Status处选择ALL,然后点击Search按钮,所有状态的Problem会被查询出来,界面如下图所示: