ASTM_E_1633_-_08a_2013e1.pdf

Designation:E163308a(Reapproved 2013)1An American National StandardStandard Specification forCoded Values Used in the Electronic Health Record1This standard is issued under the fixed designation E1633;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.1NOTEFigures reformatted as tables editorially in March 2015.1.Scope*1.1 This specification covers the identification of the lexi-cons to be used for the data elements identified inAppendix X1of Guide E1384.It is intended to unify the representations for:(1)primary record of care data elements,(2)the data elementsidentified in other standard statistical data sets,(3)dataelements used in other healthcare data message exchangeformat standards,or(4)in data gathering forms for thispurpose,and(5)in data derived from these elements in orderthat data recorded in the course of patient care be exchangeableand be the source of accurate statistical and resource manage-ment data.This specification is applicable to all paper andautomated systems.2.Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission,Discharge,Transfer(R-ADT)Systems forElectronic Health Record(EHR)SystemsE1384 Practice for Content and Structure of the ElectronicHealth Record(EHR)E1715 PracticeforAnObject-OrientedModelforRegistration,Admitting,Discharge,and Transfer(RADT)Functions in Computer-Based Patient Record SystemsE1744 Practice for View of Emergency Medical Care in theElectronic Health Record2.2 ANSI Standards:3ANS X3.50 Representation of Date and TimeANS X3.51 Representation of Common Units2.3 ISO Standards:3ISO 639 Names of LanguagesISO 2955 Representation of SI UnitsISO 3166 Names of CountriesISO 5218 Representation of Human SexesISO 8601 Representation Dates2.4 Other Standards:HL-7 Health Industry Level 7 Interface Standards43.Terminology3.1 Acronyms:3.1.1 NCHSNational Center for Health Statistics3.1.2 NCVHSNational Committee for Vital and HealthStatistics3.1.3NOSnot otherwise specified4.Significance and Use4.1 PurposeThe approval of Guide E1384,concernedwith the structure and content of the computer-based patientrecord,now includes a formal indexing of data elements and acataloging of the minimal essential value set for these ele-ments.Indexing of these data elements with a unique identifierkeyed to its position in the logical structure of Appendix X1 ofGuide E1384 now provides a means of cataloging the valuesets representing each data element(see Guide E1384).GuideE1239 describes conventions for representing many of the datavalues for data elements that are included in the more compre-hensive listing in Guide E1384.A comprehensive listing of allof the value sets associated with Guide E1384 has not yet beenassembled.This specification begins to catalog the representa-tion conventions for a number of these elements and inparticular to list the coded values.It is important that thiscatalog consider the traditionally assigned representations foreach of these elements,and it must resolve differences in amanner that introduces systematics and consistency into therepresentation.The catalog must establish both a global frame-work consistent with international standardization and withlong-term growth,while at the same time maximizing familiaror traditional representations.This standard has been devel-oped with input from many organizations,including govern-ment agencies and other standards bodies and professional1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data Management,Security,Confidentiality,and Privacy.Current edition approved April 15,2013.Published April 2013.Originallyapproved in 1996.Last previous edition approved in 2008 as E163308a.DOI:10.1520/E1633-08AR13.2For 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.4Available from Health Level 7,Mark McDougall,Executive Director,900Victors 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 associations,and as a result of the effort to achieve consistencyand comprehensiveness among the data dealt with by variousstandards efforts.4.2 General Values Early in the coordination of healthcareinformation standards an informal body,the Healthcare Infor-mation Standards Coordinating Committee(HISCC),id