ASTM E1744-04
(Practice)Standard Practice for View of Emergency Medical Care in the Electronic Health Record
Standard Practice for View of Emergency Medical Care in the Electronic Health Record
SCOPE
1.1 This practice covers the identification of the information that is necessary to document emergency medical care in an electronic, paperless patient record system that is designed to improve efficiency and cost-effectiveness.
1.2 This practice is a view of the data elements to document the types of emergency medical information that should be included in the electronic health record.
1.2.1 The patient's summary record and derived data sets will be described separately from this practice.
1.2.2 As a view of the electronic health record, the information presented will conform to the structure defined in other ASTM standards for the electronic health record.
1.3 This practice is intended to amplify Guides E 1239 and F 1629 and the formalisms described in Practices E 1384 and E 1715.
1.3.1 This practice details the use of data elements already established in these standards and other national guidelines for use during documentation of emergency care in the field or in a treatment facility and places them in the context of the object models for health care in Practice E 1384 that will be the vehicle for communication standards for health care data.
The data elements and the attributes referred to in this practice are based on national guidelines whenever available.
The EMS definitions are based on those generated from the previous EMS consensus conference sponsored by NHTSA and from ASTM task group F 30.03.03 on EMS Management Information Systems.
The Emergency Department (ED) definitions are based on the Data Elements for Emergency Department Systems (DEEDS) distributed by the Centers for Disease Control in June 1997.
The hospital discharge definitions are based on recommendations from the Centers for Medicare and Medicaid Services (CMS) for Medicare and Medicaid payment and from the Department of Health and Human Services for the Uniform Hospital Discharge Data Set.
Because the current trend is to store data as text, the codes for the attribute values have been determined as unnecessary and thus are eliminated from this document.
The ASTM process allows for the data elements to be updated as the national consensus changes. When national or professional guides do not exist, or whenever there is a conflict in the existing EMS, ED, hospital or other guides, the committee will recommend a process for resolving the conflict or an explanation of the conflict within each guide.
1.3.2 This practice reinforces the concepts set forth in Guide E 1239 and Practice E 1384 that documentation of care in all settings shall be seamless and be conducted under a common set of precepts using a common logical record structure and common terminology.
1.4 The electronic health record focuses on the patient.
1.4.1 In particular, the computer-based patient record sets out to ensure that the data document includes:
The occurrence of the emergency,
The symptoms requiring emergency medical treatment, and potential complications resulting from preexisting conditions,
The medical/mental assessment/diagnoses established,
The treatment rendered, and
The outcome and disposition of the patient after emergency treatment.
1.4.2 The electronic health record consists of subsets of data for the emergency patient that have been captured by different care providers at the time of treatment at the scene and en route, in the emergency department, and in the hospital or other emergency health care settings.
1.4.3 The electronic record focuses on the documentation of information that is necessary to support patient care but does not define appropriate care.
General Information
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Standards Content (Sample)
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An American National Standard
Designation:E1744–04
Standard Practice for
View of Emergency Medical Care in the Electronic Health
1
Record
This standard is issued under the fixed designation E1744; 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 (´) indicates an editorial change since the last revision or reapproval.
1. Scope 1.3.1.4 The hospital discharge definitions are based on
recommendations from the Centers for Medicare and Medicaid
1.1 This practice covers the identification of the information
Services (CMS) for Medicare and Medicaid payment and from
that is necessary to document emergency medical care in an
the Department of Health and Human Services for the Uniform
electronic, paperless patient record system that is designed to
Hospital Discharge Data Set.
improve efficiency and cost-effectiveness.
1.3.1.5 Because the current trend is to store data as text, the
1.2 This practice is a view of the data elements to document
codes for the attribute values have been determined as unnec-
the types of emergency medical information that should be
essary and thus are eliminated from this document.
included in the electronic health record.
1.3.1.6 The ASTM process allows for the data elements to
1.2.1 The patient’s summary record and derived data sets
be updated as the national consensus changes. When national
will be described separately from this practice.
or professional guides do not exist, or whenever there is a
1.2.2 As a view of the electronic health record, the infor-
conflict in the existing EMS, ED, hospital or other guides, the
mation presented will conform to the structure defined in other
committee will recommend a process for resolving the conflict
ASTM standards for the electronic health record.
or an explanation of the conflict within each guide.
1.3 This practice is intended to amplify Guides E1239 and
1.3.2 ThispracticereinforcestheconceptssetforthinGuide
F1629 and the formalisms described in Practices E1384 and
E1239 and Practice E1384 that documentation of care in all
E1715.
settings shall be seamless and be conducted under a common
1.3.1 This practice details the use of data elements already
set of precepts using a common logical record structure and
established in these standards and other national guidelines for
common terminology.
use during documentation of emergency care in the field or in
1.4 The electronic health record focuses on the patient.
a treatment facility and places them in the context of the object
1.4.1 In particular, the computer–based patient record sets
models for health care in Practice E1384 that will be the
out to ensure that the data document includes:
vehicle for communication standards for health care data.
1.4.1.1 The occurrence of the emergency,
1.3.1.1 The data elements and the attributes referred to in
1.4.1.2 The symptoms requiring emergency medical treat-
this practice are based on national guidelines whenever avail-
ment, and potential complications resulting from preexisting
able.
conditions,
1.3.1.2 The EMS definitions are based on those generated
1.4.1.3 The medical/mental assessment/diagnoses estab-
from the previous EMS consensus conference sponsored by
lished,
NHTSA and from ASTM task group F 30.03.03 on EMS
1.4.1.4 The treatment rendered, and
Management Information Systems.
1.4.1.5 The outcome and disposition of the patient after
1.3.1.3 The Emergency Department (ED) definitions are
emergency treatment.
based on the Data Elements for Emergency Department Sys-
1.4.2 Theelectronichealthrecordconsistsofsubsetsofdata
tems (DEEDS) distributed by the Centers for Disease Control
for the emergency patient that have been captured by different
in June 1997.
care providers at the time of treatment at the scene and en
route,intheemergencydepartment,andinthehospitalorother
1
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare
emergency health care settings.
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
Management, Security, Confidentiality, and Privacy. 1.4.3 The electronic record focuses on the documentation of
Current edition approved Nov. 1, 2004. Published November 2004. Originally
information that is necessary to support patient care but does
approved in 1995. Last previous edition approved in 1998 as E1744 – 98. DOI:
not define appropriate care.
10.1520/E1744-04.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
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E1744–04
2. Referenced Documents 3.2.4 emergency episode—a series of encounters relating to
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an emergency condition that may lead eithe
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