ASTM E1633-00

Standard Specification for Coded Values Used in the Electronic Health Record

SCOPE
1.1 This specification covers the identification of the lexicons to be used for the data elements identified in Appendix X1 of Guide E 1384. 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.

General Information

• Status: Historical
• Publication Date: 09-Jan-2002
• 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

• Replaced By: ASTM E1633-02 - Standard Specification for Coded Values Used in the Electronic Health Record
• Effective Date: 10-Jan-2002

Standards Content (Sample)

NOTICE: This standard has either been superseded and replaced by a new version or discontinued.
Contact ASTM International (www.astm.org) for the latest information.
Designation: E 1633 – 00 An American National Standard
Standard Specification for
Coded Values Used in the Electronic Health Record
This standard is issued under the fixed designation E 1633; 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.
1. Scope 2.4 Other Standards:
HL-7 Health Industry Level 7 Interface Standards
1.1 This specification covers the identification of the lexi-
cons to be used for the data elements identified in Appendix X1
3. Terminology
of Guide E 1384. It is intended to unify the representations for:
3.1 Acronyms:
(1) primary record of care data elements, (2) the data elements
3.1.1 NCHS—National Center for Health Statistics
identified in other standard statistical data sets, (3) data
3.1.2 NCVHS—National Committee for Vital and Health
elements used in other healthcare data message exchange
Statistics
format standards, or (4) in data gathering forms for this
3.1.3 NOS—not otherwise specified
purpose, and (5) in data derived from these elements in order
that data recorded in the course of patient care be exchangeable
4. Significance and Use
and be the source of accurate statistical and resource manage-
4.1 Purpose—The approval of Guide E 1384, concerned
ment data. This specification is applicable to all paper and
with the structure and content of the computer-based patient
automated systems.
record, now includes a formal indexing of data elements and a
2. Referenced Documents cataloging of the minimal essential value set for these ele-
ments. Indexing of these data elements with a unique identifier
2.1 ASTM Standards:
keyed to its position in the logical structure of Appendix X1 of
E 1238 Specification for Transferring Clinical Observations
2 Guide E 1384 now provides a means of cataloging the value
Between Independent Computer Systems
sets representing each data element (see Guide E 1384).
E 1239 Guide for Description of Reservation/
Specification E 1238, coordinated with Guide E 1239, de-
Registration—Admission, Discharge, Transfer (R-ADT)
scribes conventions for representing many of the data values
Systems for Automated Patient Care Information Systems
for data elements that are included in the more comprehensive
E 1384 Guide for Content and Structure of the Electronic
listing in Guide E 1384. A comprehensive listing of all of the
Health Record (EHR)
value sets associated with Guide E 1384 has not yet been
E 1715 Practice for an Object-Oriented Model for Registra-
assembled. This specification begins to catalog the representa-
tion, Admitting, Discharge, and Transfer (RADT) Func-
2 tion conventions for a number of these elements and in
tions in Computer-Based Record Systems
particular to list the coded values. It is important that this
E 1744 Guide for View of Emergency Medical Care in the
2 catalog consider the traditionally assigned representations for
Computer-Based Patient Record
each of these elements, and it must resolve differences in a
2.2 ANSI Standards:
manner that introduces systematics and consistency into the
ANSX 3.50 Representation of Date and Time
representation. The catalog must establish both a global frame-
ANSX 3.51 Representation of Common Units
3 work consistent with international standardization and with
2.3 ISO Standards:
long-term growth, while at the same time maximizing familiar
ISO 639 Names of Languages
or traditional representations. This standard has been devel-
ISO 2955 Representation of SI Units
oped with input from many organizations, including govern-
ISO 3166 Names of Countries
ment agencies and other standards bodies and professional
ISO 5218 Representation of Human Sexes
associations, and as a result of the effort to achieve consistency
ISO 8601 Representation Dates
and comprehensiveness among the data dealt with by various
standards efforts.
4.2 General Values—Early in the coordination of healthcare
This specification is under the jurisdiction of ASTM Committee E-31 on
information standards an informal body, the Healthcare Infor-
Healthcare Informatics and is the direct responsibility of Subcommittee E31.19 on
Electronic Health Record Content and Structure. mation Standards Coordinating Committee (HISCC), identified
Current edition approved April 10, 2000. Published June 2000. Originally
pubished as E 1633–96. Last previous edition E 1633–99.
Annual Book of ASTM Standards, Vol 14.01.
3 4
Available from American National Standards Institute, 11 W. 42nd St., 13th Available from Health Level 7, Mark McDougall, Executive Director, 900
Floor, New York, NY 10036. Victors Way, Suite 122, Ann Arbor, MI 48108.
Copyright © ASTM, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959, United States.
E 1633
certain common data element types and agreed upon conven-
14001.A163.01 Patient In-residence Transfer Type (5.2.13)
14001.A170 Diagnosis (5.2.33)
tions for representing these data element types in a standard
14001.A170.01 Diagnosis Type (5.2.34)
manner. This set the stage for the development of the value sets
14001.A170.02 Diagnosis Status Code (5.2.35)
for the CODED VALUE data type. The status of the standard
14001.A186.01 Current Clinical Status (5.2.36)
14001.A223 Source of Payment Code (5.2.21)
noncoded data types, and their representations, agreed upon by
14001.F050 Discharge Disposition Category (5.2.14)
the HISCC are:
4.2.1 Person Names—Specification E 1238, Guide E 1239
This standard identifies the current value list for each of
and HL-7 use the same representation for American and
these elements as of the approval date of this standard (see
European forms.
footnote 1) and states the evolving status of this catalog as the
4.2.2 Addresses—Common format in Specification E 1238
knowledge of the use of these elements expands as a result of
and Guide E 1239.
ongoing investigation. Each element is identified by the index
4.2.3 Telephone Numbers—Specification E 1238 and Guide
assigned to it in the revised Appendix X1 of Guide E 1384.
E 1239 currently use the same representation with area code
Moreover, the definition for that element from the Data
enclosed in parentheses and country code preceding the paren-
Element Catalog (5) is included with the value set.
theses.
5.2 Value Set Tables—These tables collect the representa-
4.2.4 Dates—Date and time represented as ANS X3.51-
tion of coded data values for specific data elements in
1986/ISO 8601-1988 with years in four digits; time not
computer-based patient record structures identified in Appen-
separated from date by “T” as permitted by ISO 8601.
dix X1 of Guide E 1384. The terms listed here are the minimal
4.2.5 Numbers—Numbers are represented either as integers
essential ones but may be further subclassified to include more
or fixed point numbers; exponential notation not presently
specific terms by appropriate extensions of the included terms.
accepted in Specification E 1238, Guide E 1239, or HL-7.
Units of Measure by ISO 2955-1983 or ANS X3.50-86. 5.2.1 Confidentiality Status—This data element, Index:
14001.A004, contains the minimal commonly used values
4.2.6 Strings—7-bit ASCII characters; multilingual charac-
ter sets not yet defined. appearing in both manual and automated systems. See Speci-
fication E 1238.
5. Assignment of Coded Values
Unwed Mother
Celebrity
5.1 The major important data elements in Guide E 1384
Psychiatric Patient
having coded data types and the current status of the cataloging
Employee
of their values are:
AIDS Patient
HIV Patient
01035 Patient Multiple Birth code (5.2.23)
Alcohol/Drug Treatment Patient
01040 Sex (5.2.20)
01042 Race (5.2.3)
5.2.2 Marital Status—This data element, Index: 01052,
01045 Ethnicity (5.2.4)
01047 Religion (5.2.7) encompasses the values noted by Westermeyer (6), Bureau of
01052 Marital status (5.2.2)
Census, the VA DHCP system, the DoD CHCS system, the
01055 Nationality/Country of Origin (5.2.6)
X12 835 Transaction Set (7), UB-82 (8), and used in common
01057 Language (5.2.5)
01060 Educational Level (5.2.8)
practice.
Educational Certification (5.2.9)
Never married
01062 Current Work Status (5.2.24)
Married
01065 Occupation (5.2.11), also 01070,01090.03
Divorced
01067 Current Vocational Status (5.2.25)
Divorced/annulled
01085 Usual Living arrangement (5.2.26)
Divorced/separated
01099 Foreign Residency Code (5.2.27)
Annulled
01090.03 Family Relationship (5.2.10)
Widowed
01155 Color Eyes (5.2.38)
Separated, NOS
01160 Color Hair (5.2.39)
Separated, legal
01175 Body Build for Identification (5.2.40)
Separated, nonlegal
02052 Durable Power of Attorney Status (5.2.28)
Marriage, separation, temporary absence
04001.50 Professional Specialty (5.2.16)
Marriage, separation, permanent absence
09001.12 Body System/Region (5.2.22)
Consentual union
14001.A002 Patient (Encounter) Type/Admission Source (5.2.17)
Unknown
14001.A004 Confidentiality Status (5.2.1)
14001.A013 Facility Care/Healthcare setting (5.2.18)
5.2.3 Race—This data element, Index: 01042, indicates the
14001.A016 Reason for Visit (5.2.19)
14001.A021 Mode of Arrival (5.2.29) region of the world from which the patient’s ancestors came.
14001.A030 Nature of Injury (5.2.30)
This is a biologic attribute that very generally indicates
14001.A033 Mode of Injury (5.2.31)
possible biologic diversity to which the patient might be
14001.A034 Product of Injury (5.2.37)
14001.A044 Protective Equipment Used (5.2.32)
subject. Due to ambiguity inherent in the diversity of the large
14001.A063 Patient Admission Type (5.2.12)
number of inherited attributes which might characterize such
14001.A110 Professional Speciality (5.2.16)
14001.A133 Accommodation type (5.2.15) ancestry, other data elements of the care record will be required
to assign meaning to the value set recorded for this attribute.
Therefore, utilization of these other attributes is strongly
5 recommended. Currently, to be consistent with census data, the
The boldface numbers in parentheses refer to the list of references at the end of
this standard. six values given in OMB Directive 15 are recommended.
E 1633
used by the Dept. of Veterans Affairs, Dept. of Defense, ANSI
American Indian/Alaska Native
Asian
X12 835 Transaction Set, UB-82 (8), and the NCVHS data
Black
sets.
Hawaiian/Pacific Islander
White Adopted Son
Other Adopted Daughter
Aunt
5.2.4 Ethnicity—In keeping with current demographic prac-
Brother
Brother-In-Law
tice, this data element, Index: 01045, reflects the ethnic cultural
Cousin
group with which the patient identifies. Multiple selections
Daughter
may be made. Each value has associated with it an ancestral
Daughter-In-Law
Father
cultural origin tag that is most closely associated with the
Father-In-Law
ancestral geographic origin of that cultural pattern. This tag
Foster Child
does not signify the ancestral biologic characteristics of the Granddaughter
Grandfather
individual which is recorded in other data elements of the
Grandmother
record. See Fig. 1.
Grandson
Great Grandfather
5.2.5 Language—This data element, Index 01058, is speci-
Great Grandmother
fied by the two character lower case code in ISO 639 Table 1.
Halfbrother
The upper case three character code, now in ISO ballotting
Halfsister
Husband
may be added in a future revision of this specification. The
Mother
language symbol only is shown here, but an original name and
Mother-In-Law
French language name are available (see Fig. 2 for list).
Nephew
Niece
5.2.6 Nationality/Country of Origin—This data element,
Sister
Index: 01055, Citizenship, is specified by ISO 3166. The two
Sister-In-Law
letter codes are shown here (see Fig. 3 for list). A three letter Son
Son-In-Law
and a numeric code exists for each entry. New entries may be
Stepbrother
added in the future.
Stepdaughter
5.2.7 Religion—This data element, Index: 01047, includes Stepfather
Stepmother
values assembled for the United States by the Dept. of Defense,
Stepsister
the Dept. of Veterans Affairs, the Bureau of Census, and the
Stepson
Uncle
NCVHS. It includes terms of general category as well as more
Unrelated, Friend
specific classifications of religious denominators (see Fig. 4 for
Ward
list).
Wife
5.2.8 Educational Level—This data element, Index: 01060,
5.2.11 Occupation—This data element, Indices: 01065.—
is stated such that the general level and year within that level
Current Occupation, 01070.—Previous Occupations and
is expressed in a way that comparably reflects the educational
0.1090.23—Family Member Occupation, reflects the terms
practice in most national settings.
used in the Standard Occupational Classification 1996 (2),
E1 to E8 Elementary
those used in the U.S. 1990 Census (1) and those in the ILO list
S1 to S4 Secondary
C1 to C5 College Baccalaureate of International Standard Classification of Occupations 1968
P1 to P9 Professional
(ISCO-68) incorporated into SNOMED (3). ISCO – 88 in-
cludes a four digit code that is the basis for several national
5.2.9 Educational Certification—This data element reflects
systems for classifying occupations. SNOMED-III, released in
the Certification of Educational Experience for credentialling
1993, continues to use ISCO-68. This scheme also includes
of healthcare practitioners. It reflects the terminology used by
terms from the Occupation Employment Survey (2) which is
the Dept. of Veterans Affairs, the Dept.of Defense, and state
being incorporated into the new classification by the US Dept.
licensing agencies.
of Labor, Bureau of Labor Statistics beginning in 1997
High School Attendance Certificate
replacing older schemes. The terms listed here from that new
Less Than High School Diploma
Certificate of High School Equivalent
scheme have been cross referenced to these older schemes in
High School Diploma
coordination with the US Dept. of Labor. The new vocabulary
1st Yr College Level Certificate
is intended to be able to also relate health care resource
College Certificate of Attendance
Associate Degree management issues to the labor market. See Fig. 5.
College Certificate of Completion
5.2.12 Patient Admission Type—This data element, Index:
Professional Nursing Diploma
14001.A063, is used to categorize the type of inpatient
Baccalaureate
First Professional Degree
encounter but is not used for other encounter types.
Masters
Admission, pre-admit (elective)
Post Masters
Admission, walk-in (urgent)
Doctorate
Admission, emergency room
Admission, referred
5.2.10 Family Relationship—This data element, Index:
Newborn
01090.03, is used to reflect the relationship of a family
member, or other person, to the patient. It includes the values 5.2.13 Patient Transfer Type—This data element: Index:
...