ASTM_E_1239_-_04_2010.pdf

Designation:E123904(Reapproved 2010)An American National StandardStandard Practice forDescription of Reservation/Registration-Admission,Discharge,Transfer(R-ADT)Systems for Electronic HealthRecord(EHR)Systems1This standard is issued under the fixed designation E1239;the number immediately following the designation indicates the year oforiginal adoption or,in the case of revision,the year of last revision.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 This practice identifies the minimum information capa-bilities needed by an ambulatory care system or a residentfacility R-ADT system.This practice is intended to depict theprocesses of:patient registration,inpatient admission intohealth care institutions and the use of registration data inestablishing and using the demographic segments of theelectronic health record.It also identifies a common core ofinformational elements needed in this R-ADT process andoutlines those organizational elements that may use thesesegments.Furthermore,this guide identifies the minimumgeneral requirements for R-ADT and helps identify many ofthe additional specific requirements for such systems.The dataelements described may not all be needed but,if used,theymust be used in the way specified so that each record segmenthas comparable data.This practice will help answer questionsfaced by designers of R-ADT capabilities by providing a cleardescription of the consensus of health care professionalsregarding a uniform set of minimum data elements used byR-ADT functions in each component of the larger system.Itwill also help educate health care professionals in the generalprinciples of patient care information management as well asthe details of the constituent specialty areas.1.2 This standard does not purport to address all of thesafety concerns,if any,associated with its use.It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory requirements prior to use.2.Referenced Documents2.1 ASTM Standards:2E1384 Practice for Content and Structure of the ElectronicHealth Record(EHR)E1633 Specification for Coded Values Used in the ElectronicHealth RecordE1714 Guide for Properties of a Universal Healthcare Iden-tifier(UHID)E1715 Practice for An Object-Oriented Model for Registra-tion,Admitting,Discharge,and Transfer(RADT)Func-tions in Computer-Based Patient Record SystemsE1869 Guide for Confidentiality,Privacy,Access,and DataSecurity Principles for Health Information Including Elec-tronic Health Records2.2 ANSI Standards:3ANS X3.38 Identification of States of the United States forInformation InterchangeANS X3.47 Structure of the Identification of Name Popu-lated Places and Related Entities of the States of theUnited StatesNCCLS LIS-5A Specification for Transferring Clinical Ob-servations Between Independent Computer SystemsNCCLS LIS-8A Guide for Functional Requirements ofClinical Laboratory Information Management SystemsNCCLS LIS-9A Guide for Coordination of Clinical Labora-tory Services within the Electronic Health Record Envi-ronment and Networked Architectures1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.25 on HealthcareData Management,Security,Confidentiality,and Privacy.This guide was preparedin collaboration with the American Health Information Management Assn.Current edition approved March 1,2010.Published August 2010.Originallyapproved in 1988.Last previous edition approved in 2004 as E123904.DOI:10.1520/E1239-04R10.2For referenced ASTM standards,visit the ASTM website,www.astm.org,orcontact ASTM Customer Service at serviceastm.org.For Annual Book of ASTMStandards volume information,refer to the standards Document Summary page onthe ASTM website.3Available from American National Standards Institute(ANSI),25 W.43rd St.,4th Floor,New York,NY 10036,http:/www.ansi.org.Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1 2.3 ISO Standards:4ISO 639 Names of LanguagesISO 3166 Names of CountriesISO 5218 Representation of Human Sexes2.4 Federal Information Processing Standard Publication:5FIPSPUB 6-2 Counties of the States of the United StatesFIPSPUB 5-1 States of the United States3.Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 admissionformal acceptance by a hospital of apatient who is to be provided with room,board,and continuousnursing services in an area of the hospital where patientsgenerally stay overnight.3.1.2 basic data set for ambulatory caredata items whichconstitute the minimum basic set of data that should be enteredin the record concerning all ambulatory medical care encoun-ters.3.1.3 clinic outpatientadmitted to a clinical service of ahospital for diagnosis or therapy on an ambulatory basis in aformally o