ASTM E1633-08A(2013)e1

Standard Specification for Coded Values Used in the Electronic Health Record (Withdrawn 2017)

ABSTRACT
This specification covers all paper and automated systems related to the identification of the lexicons to be used for the data elements intended to unify the representations for: (1) primary record of care data elements; (2) the data elements identified in other standard statistical data sets; (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose; and (5) in data derived from these elements in order that data recorded in the course of patient care be exchangeable and be the source of accurate statistical and resource management data.
SIGNIFICANCE AND USE
4.1 Purpose—The approval of Guide E1384, concerned with the structure and content of the computer-based patient record, now includes a formal indexing of data elements and a cataloging of the minimal essential value set for these elements. Indexing of these data elements with a unique identifier keyed to its position in the logical structure of Appendix X1 of Guide E1384 now provides a means of cataloging the value sets representing each data element (see Guide E1384). Guide E1239 describes conventions for representing many of the data values for data elements that are included in the more comprehensive listing in Guide E1384. A comprehensive listing of all of the value sets associated with Guide E1384 has not yet been assembled. This specification begins to catalog the representation conventions for a number of these elements and in particular to list the coded values. It is important that this catalog consider the traditionally assigned representations for each of these elements, and it must resolve differences in a manner that introduces systematics and consistency into the representation. The catalog must establish both a global framework consistent with international standardization and with long-term growth, while at the same time maximizing familiar or traditional representations. This standard has been developed with input from many organizations, including government agencies and other standards bodies and professional associations, and as a result of the effort to achieve consistency and comprehensiveness among the data dealt with by various standards efforts.  
4.2 General Values—Early in the coordination of healthcare information standards an informal body, the Healthcare Information Standards Coordinating Committee (HISCC), identified certain common data element types and agreed upon conventions for representing these data element types in a standard manner. This set the stage for the development of the value sets for the CODED VALUE data type. The sta...
SCOPE
1.1 This specification covers the identification of the lexicons to be used for the data elements identified in Appendix X1 of Guide E1384. It is intended to unify the representations for: (1) primary record of care data elements, (2) the data elements identified in other standard statistical data sets, (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose, and (5) in data derived from these elements in order that data recorded in the course of patient care be exchangeable and be the source of accurate statistical and resource management data. This specification is applicable to all paper and automated systems.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this specification was withdrawn in March 2017. This standard is being withdrawn without replacement due to its limited use by industry.

General Information

• Status: Withdrawn
• Publication Date: 14-Apr-2013
• Withdrawal Date: 17-Apr-2017
• ICS: 11.020 - Medical sciences and health care facilities in general
• ICS: 35.240.30 - IT applications in information, documentation and publishing
• Technical Committee: E31 - Healthcare Informatics
• Drafting Committee: E31.25 - Healthcare Data Management, Security, Confidentiality, and Privacy

Relations

• Replaces: ASTM E1633-08a(2013) - Standard Specification for Coded Values Used in the Electronic Health Record
• Effective Date: 15-Apr-2013

Standards Content (Sample)

NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
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Designation:E1633 −08a (Reapproved 2013) An American National Standard
Standard Specification for
Coded Values Used in the Electronic Health Record
This standard is issued under the fixed designation E1633; 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.
ε NOTE—Figures reformatted as tables editorially in March 2015.
1. Scope* ISO 3166 Names of Countries
ISO 5218 Representation of Human Sexes
1.1 This specification covers the identification of the lexi-
ISO 8601 Representation Dates
constobeusedforthedataelementsidentifiedinAppendixX1
2.4 Other Standards:
of Guide E1384. It is intended to unify the representations for:
HL-7 Health Industry Level 7 Interface Standards
(1) primary record of care data elements, (2) the data elements
identified in other standard statistical data sets, (3) data
3. Terminology
elements used in other healthcare data message exchange
format standards, or (4) in data gathering forms for this 3.1 Acronyms:
purpose, and (5) in data derived from these elements in order
3.1.1 NCHS—National Center for Health Statistics
thatdatarecordedinthecourseofpatientcarebeexchangeable
3.1.2 NCVHS—National Committee for Vital and Health
and be the source of accurate statistical and resource manage-
Statistics
ment data. This specification is applicable to all paper and
3.1.3 NOS—not otherwise specified
automated systems.
2. Referenced Documents 4. Significance and Use
2.1 ASTM Standards: 4.1 Purpose—The approval of Guide E1384, concerned
E1239 Practice for Description of Reservation/Registration- with the structure and content of the computer-based patient
Admission, Discharge, Transfer (R-ADT) Systems for record, now includes a formal indexing of data elements and a
Electronic Health Record (EHR) Systems cataloging of the minimal essential value set for these ele-
E1384 Practice for Content and Structure of the Electronic ments. Indexing of these data elements with a unique identifier
Health Record (EHR) keyed to its position in the logical structure ofAppendix X1 of
E1715 Practice for An Object-Oriented Model for Guide E1384 now provides a means of cataloging the value
Registration,Admitting, Discharge, and Transfer (RADT) sets representing each data element (see Guide E1384). Guide
Functions in Computer-Based Patient Record Systems E1239 describes conventions for representing many of the data
E1744 Practice for View of Emergency Medical Care in the values for data elements that are included in the more compre-
Electronic Health Record hensive listing in Guide E1384.Acomprehensive listing of all
2.2 ANSI Standards: of the value sets associated with Guide E1384 has not yet been
ANS X3.50 Representation of Date and Time assembled. This specification begins to catalog the representa-
ANS X3.51 Representation of Common Units tion conventions for a number of these elements and in
2.3 ISO Standards: particular to list the coded values. It is important that this
ISO 639 Names of Languages catalog consider the traditionally assigned representations for
ISO 2955 Representation of SI Units each of these elements, and it must resolve differences in a
manner that introduces systematics and consistency into the
This specification is under the jurisdiction of ASTM Committee E31 on representation.The catalog must establish both a global frame-
Healthcare Informatics and is the direct responsibility of Subcommittee E31.25 on
work consistent with international standardization and with
Healthcare Data Management, Security, Confidentiality, and Privacy.
long-term growth, while at the same time maximizing familiar
Current edition approved April 15, 2013. Published April 2013. Originally
or traditional representations. This standard has been devel-
approved in 1996. Last previous edition approved in 2008 as E1633–08a. DOI:
10.1520/E1633-08AR13.
oped with input from many organizations, including govern-
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
ment agencies and other standards bodies and professional
contact ASTM Customer Service at [e-mail]. For Annual Book of ASTM
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website.
Available fromAmerican National Standards Institute (ANSI), 25 W. 43rd St., Available from Health Level 7, Mark McDougall, Executive Director, 900
4th Floor, New York, NY 10036, http://www.ansi.org. Victors Way, Suite 122, Ann Arbor, MI 48108.
*A Summary of Changes section appears at the end of this standard
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
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E1633−08a (2013)
associations, and as a result of the effort to achieve consistency
09001.30.05 Tooth Surface (5.2.75)
09001.30.06 Tooth Sensitivity Code (5.2.65)
and comprehensiveness among the data dealt with by various
09001.30.07 Tooth Mobility Code (5.2.66)
standards efforts.
09001.40.1 Prosthesis Type (5.2.67)
11001.01.24 Test Specimen Source (5.2.68)
4.2 General Values—Earlyinthecoordinationofhealthcare
14001.A002 Patient (Encounter) Type/Admission Source (5.2.17)
information standards an informal body, the Healthcare Infor-
14001.A004 Confidentiality Status (5.2.1)
14001.A010 Encounter Status (5.2.69)
mationStandardsCoordinatingCommittee(HISCC),identified
14001.A013 Facility Care/Healthcare setting (5.2.18)
certain common data element types and agreed upon conven-
14001.A016 Reason for Visit (5.2.19)
tions for representing these data element types in a standard
14001.A020 Encounter patient Arrival Condition (5.2.70)
manner.Thissetthestageforthedevelopmentofthevaluesets 14001.A021 Mode of Arrival (5.2.29)
14001.A030 Nature of Injury (5.2.30)
for the CODED VALUE data type. The status of the standard
14001.A033 Mode of Injury (5.2.31)
noncoded data types, and their representations, agreed upon by
14001.A034 Product of Injury (5.2.37)
14001.A040 Injury On the Job Status (5.2.71)
the HISCC are:
14001.A044 Protective Equipment Used (5.2.32)
4.2.1 Person Names— Guide E1239, Practice E1715, Prac-
14001.A063 Patient Admission Type (5.2.12)
tice E1744, and HL-7 use the same representation for Ameri-
14001.A110 Professional Specialty (5.2.16)
14001.A133 Accommodation type (5.2.15)
can and European forms.
14001.A163.01 Patient In-residence Transfer Type (5.2.13)
4.2.2 Addresses—CommonformatinGuideE1239,Practice
14001.A170 Diagnosis (5.2.33)
E1715, and Practice E1744.
14001.A170.01 Diagnosis Type (5.2.34)
14001.A170.02 Diagnosis Status Code (5.2.35)
4.2.3 Telephone Numbers—Guide E1239 currently uses the
14001.A186.01 Current Clinical Status (5.2.36)
samerepresentationwithareacodeenclosedinparenthesesand
14001.A206 Police Hold Status (5.2.72)
country code preceding the parentheses.
14001.A213 Medical Examiner Notification Code (5.2.73)
14001.A223 Source of Payment Code (5.2.21)
4.2.4 Dates—Date and time represented as ANS X3.51-
14001.F050 Discharge Disposition Category (5.2.14)
1986/ISO 8601-1988 with years in four digits; time not
This standard identifies the current value list for each of
separated from date by “T” as permitted by ISO 8601.
these elements as of the approval date of this standard (see
4.2.5 Numbers—Numbers are represented either as integers
footnote 1) and states the evolving status of this catalog as the
or fixed point numbers; exponential notation not presently
knowledge of the use of these elements expands as a result of
accepted in Guide E1239 or HL-7. Units of Measure by ISO
ongoing investigation. Each element is identified by the index
2955-1983 or ANS X3.50-86.
assigned to it in the revised Appendix X1 of Guide E1384.
4.2.6 Strings—7-bit ASCII characters; multilingual charac-
Moreover, the definition for that element from the Data
ter sets not yet defined.
Element Catalog (1) is included with the value set.
5. Assignment of Coded Values
5.2 Value Set Tables—Thesetablescollecttherepresentation
5.1 The major important data elements in Guide E1384
of coded data values for specific data elements in computer-
havingcodeddatatypesandthecurrentstatusofthecataloging
based patient record structures identified in Appendix X1 of
of their values are:
Guide E1384. The terms listed here are the minimal essential
01035 Patient Multiple Birth code (5.2.23) ones but may be further subclassified to include more specific
01040 Sex (5.2.20)
terms by appropriate extensions of the included terms.
01042 Biogeographic Ancestry (Race) (5.2.3)
5.2.1 Confidentiality Status—This data element, Index:
01045 Ethnicity (5.2.4)
01047 Religion (5.2.7) 14001.A004, contains the minimal commonly used values
01052 Marital status (5.2.2)
appearing in both manual and automated systems.
01055 Nationality/Country of Origin (5.2.6)
01057 Language (5.2.5) Unwed mother UWM
01060 Educational Level (5.2.8) Celebrity VIP
Educational Certification (5.2.9)
Psychiatric patient PSY
01062 Current Work Status (5.2.24) Employee EMP
01065 Occupation (5.2.11) also 01070,01090.03 AIDS patient AID
01067 Current Vocational Status (5.2.25) HIV patient HIV
01085 Usual Living arrangement (5.2.26) Alcohol/Drug patient ETH
01099 Foreign Residency Code (5.2.27) Usual control U
01090.03 Family Relationship (5.2.10) Restricted R
01155 Color Eyes (5.2.38) Very restricted V
01160 Color Hair (5.2.39)
5.2.2 Marital Status—This data element, Index: 01052,
01175 Body Build for Identification (5.2.40)
02052 Durable Power of Attorney Status (5.2.28)
encompasses the values noted by Westermeyer (2), Bureau of
06001.01.15 Immunization reaction/result (5.2.63)
Census, the VA DHCP system, the DoD CHCS system, the
04001.50 Professional Specialty (5.2.16)
X12 835 Transaction Set (3) , UB-82 (4), and used in common
08005 Birth method (5.2.64)
08095 Health History Response (5.2.76)
practice.
09001.12 Body System/Region (5.2.22)
Never married B
09001.13 Exam Finding (5.2.77)
Single S
09001.30 Tooth ID (5.2.74)
Married M
Divorced D
Divorced/annulled L
Divorced/separated H
The boldface numbers in parentheses refer to the list of references at the end of
Annulled N
this standard.
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E1633−08a (2013)
Widowed W AFRICA:EAST AFRICA 0220-
Separated, NOS A AFRICA:SOUTHERN AFRICA 0221-
Separated, legal E
Separated, nonlegal K AMERICA:NOS 1002-5 AMERICAN INDIAN/
Marriage, separation, temporary absence X ALASKA NATIVE
Marriage, separation, permanent absence V AMERICA:NORTH AMERICA 0222-
Consensual union J (ABORIGINAL)
Unknown U AMERICA:CENTRALAMERICA/ 0223-
Common Law C CARIBBEAN (ABORIGINAL)
Domestic Partner P AMERICA:SOUTH AMERICA 0224-
Registered Domestic Partner R
EAST ASIA:NOS 2028-9 ASIAN
Living together G
Interlocutory I EAST ASIA:CENTRALASIA 0225-
EAST ASIA:NORTHERN ASIA 0226-
Other O
Unreported T EAST ASIA:EAST ASIA 0227-
EAST ASIA:SOUTH ASIA 0228-
5.2.3 Biogeographic Ancestry (previously stated as:
EAST ASIA:SOUTHEAST ASIA 0229-
Race)——This data element, Index: 01042, indicates the re-
EAST ASIA:AUSTRALIA (ABORIGINAL) 0230-
gion of the world from which the patient’s ancestors came.
EURASIA:NOS 2106-3 WHITE
This is a biologic attribute that very generally indicates
EURASIA:WESTERN EUROPE 0231-
possible biologic diversity to which the patient might be EURASIA:NORTHERN EUROPE 0232-
EURASIA:EASTERN EUROPE 0233-
subject. Due to ambiguity inherent in the diversity of the large
EURASIA:SOUTHERN EUROPE/ 0234-
number of inherited attributes which might characterize such
MEDITERANIAN
ancestry,otherdataelementsofthecarerecordwillberequired EURASIA:NORTH AFRICA 0235-
EURASIA:NEAR EAST 0236-
to assign full meaning to the value set recorded for this
EURASIA:ARABIAN PENINSULA 0237-
attribute. The name originates from recommendations in the
EURASIA:WESTERN EURASIA 0238-
genetics literature (Am J Hum Gent 77:519-532 2005).
OCEANIA:NOS 2076-8 HAWAIIAN/
Therefore, utilization of these other attributes is strongly
PACIFIC ISLANDER
recommended.Tobeconsistentwithcensusdata,thesixvalues
OCEANIA:PACIFIC ISLANDS 0239-
currently given in OMB Directive 15 are shown for relation-
OTHER 2131-3
ship to the recommended new terms. New subcategories may
be added as recommended by the genetics professional disci-
5.2.4 Ethnicity—In keeping with current demographic
plines. The check digit for the code is calculated via program
practice, this data element, Index: 01045, reflects the ethnic
showninAppendixX1.NotethatNOSinthetermmeans“Not
cultural group with which the patient identifies. Multiple
Otherwise Specified.”
selections may be made. Each value has associated with it an
Proposed Term Code Present Term ancestralculturalorigintagthatismostcloselyassociatedwith
the ancestral geographic origin of that cultural pattern.This tag
AFRICA:NOS 2054-5 BLACK
does not signify the ancestral biologic characteristics of the
AFRICA:WEST AFRICA 0218-
AFRICA:CENTRALSUB- 0219-
individual which is recorded in other data elements of the
SAHARAN AFRICA
record. See Table 1.
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E1633−08a (2013)
TABLE 1 Ethnic Group
CDC Unique ID Name
1070-2 AMER IND/ALASKA NAT:CENTRALAMER IND,NOS
2162-6 AMER IND/ALASKA NAT:CENTRALAMERICAN IND,HISPANIC,NOS
0128- AMER IND/ALASKA NAT:HISPANIC,CUBAN
2153-5 AMER IND/ALASKA NAT:HISPANIC,MEXICAN
0131- AMER IND/ALASKA NAT:HISPANIC:PUERTO RICAN
0130- AMER IND/ALASKA NAT:LATIN AMERICAN,HISP DESCENT,NOS
0129- AMER IND/ALASKA NAT:LATIN AMERICAN,OTHER DESCENT
1002-5 AMER IND/ALASKA NAT:NOS
1073-6 AMER IND/ALASKA NAT:SOUTH AMERICAN IND,NOS
2175-8 AMER IND/ALASKA NAT:SOUTH AMERICAN IND,HISPANIC,NOS
1986-9 AMER IND/ALASKA NAT:US CAN IND,ALEUT,CHUGACH CORPORATION
1966-1 AMER IND/ALASKA NAT:US/CAN IND,ALEUT,NOS
1840-8 AMER IND/ALASKA NAT:US/CAN IND,INUIT,NOS
1004-1 AMER IND/ALASKA NAT:US/CAN IND,NOS
0132- AMER IND/ALASKA NAT:US/CAN IND,ALABAMA
0133- AMER IND/ALASKA NAT:US/CAN IND,COUSHATTA
1010-8 AMER IND/ALASKA NAT:US/CAN IND,APACHE
1026-4 AMER IND/ALASKA NAT:US/CAN IND,ARIKARA
1021-5 AMER IND/ALASKA NAT:US/CAN IND,ARAPAHOE,NOS
1028-0 AMER IND/ALASKA NAT:US/CAN IND,ASSINIBOINE
1033-0 AMER IND/ALASKA NAT:US/CAN IND,BANNOCK
1035-5 AMER IND/ALASKA NAT:US/CAN IND,BLACKFOOT
1044-7 AMER IND/ALASKA NAT:US/CAN IND,CAHUILLA
0125- AMER IND/ALASKA NAT:US/CAN IND,COPALIS
1078-5 AMER IND/ALASKA NAT:US/CAN IND,CAYUSE
1393-8 AMER IND/ALASKA NAT:US/CAN IND,CELILO
1088-4 AMER IND/ALASKA NAT:US/CAN IND,CHEROKEE,NOS
1102-3 AMER IND/ALASKA NAT:US/CAN IND,CHEYENNE,NOS
1112-2 AMER IND/ALASKA NAT:US/CAN IND,CHICKASAW
1816-8 AMER IND/ALASKA NAT:US/CAN IND,CHILKAT
1114-8 AMER IND/ALASKA NAT:US/CAN IND,CHINOOK,NOS
1123-9 AMER IND/ALASKA NAT:US/CAN IND,CHI
...