ASTM_E_2184_-_02.pdf

Designation:E 2184 02An American National StandardStandard Specification forHealthcare Document Formats1This standard is issued under the fixed designation E 2184;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(e)indicates an editorial change since the last revision or reapproval.1.Scope1.1 This specification addresses requirements for the head-ings,arrangement,and appearance of sections and subsectionswhen used within an individuals healthcare documents.Thisspecification will facilitate identification and retrieval of healthinformation in a manner that will enhance the quality andefficiency of health services.Use of this specification inconjunction with XML DTDs(extensible markup languagedocument type definitions)and the EHR(electronic healthrecords)would further enhance efficiency in time and cost.This specification applies across multiple healthcare settings inwhich healthcare documents are generated,such as hospitals,clinics,skilled nursing facilities,ambulatory care facilities,outpatient surgery centers,and private healthcare providersoffices.1.2 This specification addresses the headings,arrangement,and appearance of sections and subsections of healthcaredocuments,however generated(dictation/transcription,speechrecognition,touch-screen entry,and so forth)and whetherdisplayed electronically or on paper.It does not address thetitles of healthcare documents or the content of sections andsubsections.1.2.1 The author of a healthcare document may choose tosummarize subsection information within a general sectionrather than creating subsections.1.3 The format and content of patient-identifying data areaddressed in Guide E 1384.1.4 Issues of confidentiality and security are addressed inGuide E 1869,Guide E 1902,Guide E 1762,Guide E 1985,Guide E 1986,Guide E 1987,Guide E 1988,SpecificationE 2084,Guide E 2085,and Guide E 2086,as well as inSpecification E 2147.1.5 Issues of XML DTDs are addressed in SpecificationE 2182 and Guide E 2183.2.Referenced Documents2.1 ASTM Standards:E 1384 Guide for Content and Structure of the ElectronicHealth Record(EHR)2E 1762 Guide for Electronic Authentication of Health CareInformation2E 1869 Guide for Confidentiality,Privacy,Access,and DataSecurity Principles for Health Information includingComputer-Based Patient Records2E 1902 Guide for Management of the Confidentiality andSecurity of Dictation,Transcription,and TranscribedHealth Records2E 1985 Guide for User Identification and Authorization2E 1986 Guide for Information Access Privileges to HealthInformation2E 1987 Guide for Individual Rights Regarding Health In-formation2E 1988 Guide for Training of Persons Who Have Access toHealth Information2E 2084 Specification for Authentication of Healthcare In-formation Using Digital Signatures2E 2085 Guide on Security Framework for Healthcare Infor-mation2E 2086 Guide for Internet and Intranet Healthcare Security2E 2147 Specification for Audit and Disclosure Logs for usein Health Information Systems2E 2182 Specification for Clinical XML DTDs in Health-care2E 2183 Guide for XML DTD Design,Architecture,andImplementation23.Terminology3.1 Definitions:3.1.1 alias,nheading synonymous with and which shallbe replaced by the specified heading.No alias(synonym)shallbe used in place of the specified heading.The aliases presentedare examples only,that is,no attempt has been made to identifyall potential aliases.3.1.2 amendment,na correction or addendum to a docu-ment.3.1.3 author,nthe person originating content for a health-care document.3.1.4 document,nsee healthcare document.3.1.5 format,nthe arrangement of the content of a health-care document for display.In this specification,format refers to1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.28 onElectronic Healthcare Records.Current edition approved Jan.10,2002.Published March 2002.2Annual Book of ASTM Standards,Vol 14.01.1Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959,United States.the sequencing of the sections and subsections used in ahealthcare document,the appearance of their headings,theirline spacing,and their alignment.3.1.6 healthcare document,nhealthcare information,however generated,pertinent to a specific individual andrecorded to serve a specific use.3.1.7 healthcare information,nworded,numeric,imaged,or data-streamed material used to communicate the healthcareexperience of,and related services for,an individual.3.1.8 health record,nhealthcare information retrievablefrom one or more sources,however displayed,pertinent to anindividual,used to describe and measure that individualshealth status and health care over time and across settings,tofacilitate healthcare management through one or more episodesof care,including pre