ASTM E1384-99e1
Historical Standard: ASTM E1384-99e1 Standard Guide for Content and Structure of the Electronic Health Record (EHR)
SUPERSEDED (see Active link, below)
ASTM E1384
1. Scope
1.1 This guide covers all types of healthcare services, including those given in acute care hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments as well as ambulatory care. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). At this time, the standard vocabulary reflects more traditional care. As the standard evolves in the next revisions, the vocabulary will more adequately encompass the entire continuum of care through all delivery models, health status measurement, preventive case, and health education content.
1.2 This guide has five purposes. The first is to identify the content and logical structure of a Electronic Health Record (EHR). The record carries all health related information about a patient over time. It includes such things as observations or descriptions of the patient (for example, the physician's or nurse practitioner's history and physical, laboratory tests, diagnostic imaging reports), provider's orders for observations and treatments, documentation about the actions carried out (for example, therapies or drugs administered), patient identifying information, legal permissions, and so on.
1.2.1 The second goal is to define the relationship of data coming from diverse source systems (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and the data stored in the Electronic Health Record. Recalling that the EHR is the primary repository for information from various sources, the structure of the EHR is receptive to the data that flow from other systems.
1.2.2 Third, in order to accelerate the adoption of EHRs, this guide provides a common vocabulary, perspective, and references for those developing, purchasing, and implementing EHR systems, but it does not deal either with implementation or procurement.
1.2.3 Fourth, this guide describes examples of a variety of views by which the logical data structure might be accessed/displayed in order to accomplish various functions.
1.2.4 Fifth, this guide relates the logical structure of the EHR to the essential documentation currently used in the healthcare delivery system within the United States in order to promote consistency and efficient data transfer. It maps to the clinical data currently in existing data systems and patient care records.
2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.
ASTM Standards
E1238 Specification for Transferring Clinical Observations Between Independent Computer Systems
E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
E1633 Specification for Coded Values Used in the Electronic Health Record
E1639 Guide for Functional Requirements of Clinical Laboratory Information Management Systems
E1714 Guide for Properties of a Universal Healthcare Identifier (UHID)
E1715 Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
E1769 Guide for Properties of Electronic Health Records and Record Systems
E2118 Guide for Coordination of Clinical Laboratory Services within the Electronic Health Record Environment and Networked Architectures
E2369 Specification for Continuity of Care Record (CCR)
E2473 Practice for the Occupational/Environmental Health View of the Electronic Health Record
E2538 Practice for Defining and Implementing Pharmacotherapy Information Services within the Electronic Health Record (EHR) Environment and Networked Architectures
HL007
Other Health Informatics Standards
X12.87 Healthcare Claim Transaction Set (837)ANSI Standards
HealthInformationMan Glossary, American Health Information Management Association, 2006Keywords
data type; data views; EHR principles; electronic health record; master table; objects; segments;
ICS Code
ICS Number Code 01.140.20 (Information sciences); 35.240.30 (IT applications in information, documentation and publishing)
DOI: 10.1520/E1384-99E01
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