ASTM_E_1384_-_07_2013.pdf

Designation:E138407(Reapproved 2013)An American National StandardStandard Practice forContent and Structure of the Electronic Health Record(EHR)1This standard is issued under the fixed designation E1384;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.Scope*1.1 This practice covers all types of healthcare services,including those given in ambulatory care,hospitals,nursinghomes,skilled nursing facilities,home healthcare,and spe-cialty care environments.They apply both to short termcontacts(for example,emergency rooms and emergency medi-cal service units)and long term contacts(primary care physi-cians with long term patients).The vocabulary aims to encom-pass the continuum of care through all delivery models.Thispractice defines the persistent data needed to support ElectronicHealth Record system functionality.1.2 This practice has four purposes:1.2.1 Identify the content and logical data structure andorganization of an Electronic Health Record(EHR)consistentwith currently acknowledged patient record content.The re-cord carries all health related information about a person overtime.It may include history and physical,laboratory tests,diagnostic reports,orders and treatments documentation,pa-tient identifying information,legal permissions,and so on.Thecontent is presented and described as data elements or asclinical documents.This standard is consistent with eXtensibleMarkup Language(XML).See Document Type Definition(DTD)2.1 and W3CXML Schema 1.01.2.2 Explain the relationship of data coming from diversesources(for example,clinical laboratory information manage-ment systems,order entry systems,pharmacy informationmanagement systems,dictation systems),and other data in theElectronic Health Record as the primary repository for infor-mation from various sources.1.2.3 Provide a common vocabulary for those developing,purchasing,and implementing EHR systems.1.2.4 Provide sufficient content from which data extractscan be compiled to create unique setting“views.”1.2.5 Map the content to selected relevant biomedical andhealth informatics standards.2.Referenced Documents2.1 ASTM Standards:2E1238 Specification for Transferring Clinical ObservationsBetween Independent Computer Systems(Withdrawn2002)3E1239 Practice for Description of Reservation/Registration-Admission,Discharge,Transfer(R-ADT)Systems forElectronic Health Record(EHR)SystemsE1633 Specification for Coded Values Used in the ElectronicHealth RecordE1639 Guide for Functional Requirements of Clinical Labo-ratory Information Management Systems(Withdrawn2002)3E1714 Guide for Properties of a Universal Healthcare Iden-tifier(UHID)E1715 PracticeforAnObject-OrientedModelforRegistration,Admitting,Discharge,and Transfer(RADT)Functions in Computer-Based Patient Record SystemsE1769 Guide for Properties of Electronic Health Recordsand Record SystemsE2118 Guide for Coordination of Clinical Laboratory Ser-vices within the Electronic Health Record Environmentand Networked Architectures(Withdrawn 2002)3E2369 Specification for Continuity of Care Record(CCR)E2473 Practice for the Occupational/Environmental HealthView of the Electronic Health RecordE2538 Practice for Defining and Implementing Pharmaco-therapy Information Services within the Electronic HealthRecord(EHR)Environment and Networked ArchitecturesHL72.2 Other Health Informatics Standards:HL7 Health Level Seven(HL7)Version 2.2 19944(Version2.4 and 2.5)NCPDP National Council for Prescription Drug Programs1This 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.Current edition approved April 15,2013.Published April 2013.Originallyapproved in 1991.Last previous edition approved in 2007 as E1384 07.DOI:10.1520/E1384-07R13.2For 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.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from HL7,Mark McDougall,Executive Director,900 Victors Way,Suite 122,Ann Arbor,MI 48108.*A Summary of Changes section appears at the end of this standardCopyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1(NCPDP)Telecommunication Standard Format Version3 Release 2,19925ANSI ASC X12:Version 3,Release 3(1992)6X12.84 Healthcare Enrollment and Maintenance TransactionSet(834)7X12.85 Healthcare Claim Payment Transaction Set(835)7X12.87 Healthcare Claim Transaction Set(837)72.3 ANSI Standards:7HL7 EHR TC Electronic Health Record-System Functional