ASTM_E_1744_-_04_2010.pdf

Designation:E174404(Reapproved 2010)An American National StandardStandard Practice forView of Emergency Medical Care in the Electronic HealthRecord1This standard is issued under the fixed designation E1744;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 covers the identification of the informationthat is necessary to document emergency medical care in anelectronic,paperless patient record system that is designed toimprove efficiency and cost-effectiveness.1.2 This practice is a view of the data elements to documentthe types of emergency medical information that should beincluded in the electronic health record.1.2.1 The patients summary record and derived data setswill be described separately from this practice.1.2.2 As a view of the electronic health record,the infor-mation presented will conform to the structure defined in otherASTM standards for the electronic health record.1.3 This practice is intended to amplify Guides E1239 andF1629 and the formalisms described in Practices E1384 andE1715.1.3.1 This practice details the use of data elements alreadyestablished in these standards and other national guidelines foruse during documentation of emergency care in the field or ina treatment facility and places them in the context of the objectmodels for health care in Practice E1384 that will be thevehicle for communication standards for health care data.1.3.1.1 The data elements and the attributes referred to inthis practice are based on national guidelines whenever avail-able.1.3.1.2 The EMS definitions are based on those generatedfrom the previous EMS consensus conference sponsored byNHTSA and from ASTM task group F 30.03.03 on EMSManagement Information Systems.1.3.1.3 The Emergency Department(ED)definitions arebased on the Data Elements for Emergency Department Sys-tems(DEEDS)distributed by the Centers for Disease Controlin June 1997.1.3.1.4 The hospital discharge definitions are based onrecommendations from the Centers for Medicare and MedicaidServices(CMS)for Medicare and Medicaid payment and fromthe Department of Health and Human Services for the UniformHospital Discharge Data Set.1.3.1.5 Because the current trend is to store data as text,thecodes for the attribute values have been determined as unnec-essary and thus are eliminated from this document.1.3.1.6 The ASTM process allows for the data elements tobe updated as the national consensus changes.When nationalor professional guides do not exist,or whenever there is aconflict in the existing EMS,ED,hospital or other guides,thecommittee will recommend a process for resolving the conflictor an explanation of the conflict within each guide.1.3.2 This practice reinforces the concepts set forth in GuideE1239 and Practice E1384 that documentation of care in allsettings shall be seamless and be conducted under a commonset of precepts using a common logical record structure andcommon terminology.1.4 The electronic health record focuses on the patient.1.4.1 In particular,the computerbased patient record setsout to ensure that the data document includes:1.4.1.1 The occurrence of the emergency,1.4.1.2 The symptoms requiring emergency medical treat-ment,and potential complications resulting from preexistingconditions,1.4.1.3 The medical/mental assessment/diagnoses estab-lished,1.4.1.4 The treatment rendered,and1.4.1.5 The outcome and disposition of the patient afteremergency treatment.1.4.2 The electronic health record consists of subsets of datafor the emergency patient that have been captured by differentcare providers at the time of treatment at the scene and enroute,in the emergency department,and in the hospital or otheremergency health care settings.1.4.3 The electronic record focuses on the documentation ofinformation that is necessary to support patient care but doesnot define appropriate care.1This 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 March 1,2010.Published August 2010.Originallyapproved in 1995.Last previous edition approved in 2004 as E174404.DOI:10.1520/E1744-04R10.Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1 2.Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission,Discharge,Transfer(R-ADT)Systems forElectronic Health Record(EHR)Systems(Withdrawn2001)3E1384 Practice for Content and Structure of the ElectronicHealth Record(EHR)(Withdrawn 2001)3E1633 Specification for Coded Values Used in the ElectronicHealth Record(Withdrawn 2001)3E1715 Practice for An Object-Oriented Model for Regi