ASTM E1384-02a
(Guide)Practice for Content and Structure of the Electronic Health Record (EHR)
Practice for Content and Structure of the Electronic Health Record (EHR)
SCOPE
1.1 This guide covers all types of healthcare services, including those given in acute care hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments as well as ambulatory care. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). At this time, the standard vocabulary reflects more traditional care. As the standard evolves in the next revisions, the vocabulary will more adequately encompass the entire continuum of care through all delivery models, health status measurement, preventive case, and health education content.
1.2 This guide has five purposes. The first is to identify the content and logical structure of a Electronic Health Record (EHR). The record carries all health related information about a patient over time. It includes such things as observations or descriptions of the patient (for example, the physician's or nurse practitioner's history and physical, laboratory tests, diagnostic imaging reports), provider's orders for observations and treatments, documentation about the actions carried out (for example, therapies or drugs administered), patient identifying information, legal permissions, and so on.
1.2.1 The second goal is to define the relationship of data coming from diverse source systems (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and the data stored in the Electronic Health Record. Recalling that the EHR is the primary repository for information from various sources, the structure of the EHR is receptive to the data that flow from other systems.
1.2.2 Third, in order to accelerate the adoption of EHRs, this guide provides a common vocabulary, perspective, and references for those developing, purchasing, and implementing EHR systems, but it does not deal either with implementation or procurement.
1.2.3 Fourth, this guide describes examples of a variety of views by which the logical data structure might be accessed/displayed in order to accomplish various functions.
1.2.4 Fifth, this guide relates the logical structure of the EHR to the essential documentation currently used in the healthcare delivery system within the United States in order to promote consistency and efficient data transfer. It maps to the clinical data currently in existing data systems and patient care records.
General Information
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Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
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An American National Standard
Designation:E1384–02a
Standard Practice for
Content and Structure of the Electronic Health Record
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(EHR)
This standard is issued under the fixed designation E 1384; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
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1. Scope Automated Patient Care Information Systems
E 1381 Specification for Low-Level Protocol to Transfer
1.1 This practice covers all types of healthcare services,
Messages Between Clinical Instruments and Computer
including those given in ambulatory care, hospitals, nursing
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Systems
homes, skilled nursing facilities, home healthcare, and spe-
E 1394 Specification for Transferring Information Between
cialty care environments. They apply both to short term
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Clinical Instruments and Computer Systems
contacts (for example, emergency rooms and emergency medi-
E 1460 Specification for Defining and Sharing Modular
cal service units) and long term contacts (primary care physi-
HealthKnowledgeBases(ArdenSyntaxforMedicalLogic
cians with long term patients). The vocabulary aims to encom-
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Modules)
pass the continuum of care through all delivery models.
E 1467 Specification for Transferring Digital Neurophysi-
1.2 This practice has four purposes:
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ological Data Between Independent Computer Systems
1.2.1 Identify the content and logical structure of an Elec-
E 1633 Specification for the Coded Values Used in the
tronicHealthRecord(EHR)consistentwithcurrentlyacknowl-
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Computer-Based Patient Record
edged patient record content. The record carries all health
E 1712 Specification for Representing Clinical Laboratory
related information about a person over time. It may include
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Test and Analyte Names
historyandphysical,laboratorytests,diagnosticreports,orders
E 1714 Guide for Properties of a Universal Healthcare
and treatments documentation, patient identifying information,
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Identifier
legal permissions, and so on.
E 1715 Practice for an Object-Oriented Model for Registra-
1.2.2 Explain the relationship of data coming from diverse
tion, Admitting, Discharge, and Transfer (RADT) Func-
sources (for example, clinical laboratory information manage-
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tions in Computer Based Patient Record Systems
ment systems, order entry systems, pharmacy information
E 1769 Guide for Properties of Electronic Health Records
management systems, dictation systems), and other data in the
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and Record Systems
Electronic Health Record as the primary repository for infor-
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2.2 ISO Standards:
mation from various sources.
IS 5218 1977 Information Interchange—Representation of
1.2.3 Provide a common vocabulary for those developing,
Human Sexes
purchasing, and implementing EHR systems.
IS 1000 1981 SI Units and Recommendations for the Use of
1.2.4 Provide sufficient content from which data extracts
Their Multiples and of Certain Other Units
can be compiled to create unique setting “views.”
IS 2955 1983 Information Processing—Representation of
2. Referenced Documents SI and Other Units in Systems with Limited Character
Sets
2.1 ASTM Standards:
IS 8072 1984 Information Processing Standard—Open Sys-
E 792 Guide for Selection of a Clinical Laboratory Infor-
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tem Interconnection Transport Service Definition
mation Management System
IS 8601 1988 Data Elements and Interchange Formats—
E 1238 Specification for Transferring Clinical Observations
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Information Interchange (Representation of Dates and
Between Independent Computer Systems
Times)
E 1239 Guide for Description of Reservation/Registration-
IS 6937:1994 Information Technology—Coded Graphic
Admission, Discharge, Transfer (R-ADT) Systems for
Character Set for Text Communication (Revision of Parts
1 and 2)
IS 10367:1991 Standardized Coded Graphic Character Sets
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This practice is under the jurisdiction ofASTM Committee E31 on Healthcare
for Use in 8 Bit Codes
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
Data Management, Security, Confidentiality, and Privacy.
Current edition approved Sept. 10, 2002. Published January 2003. Originally
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published as E 1384 – 91. Last previous edition E 1384 – 02. Available from International Organization for Standardization (ISO), 1 rue de
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Annual Book of ASTM Standards, Vol 14.01. Varembé, Case postale 56, CH-1211, Geneva 20, Switzerland.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
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E1384–02a
2.3 Other Health Informatics Standards: 3.1.6 clinic patient—admitted for diagnosis or treatment or
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HL7 Health Level Seven (HL7) Version 2.2 1994 follow-up on an amb
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