ASTM E1239-00
(Guide)Standard Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
Standard Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
SCOPE
1.1 This guide identifies the minimum information capabilities needed by an ambulatory care system or a resident facility R-ADT system. This guide is intended to depict the processes of: patient registration, inpatient admission into health care institutions and the use of registration data in establishing and using the demographic segments of the electronic health record. It also identifies a common core of informational elements needed in this R-ADT process and outlines those organizational elements that may use these segments. Furthermore, this guide identifies the minimum general requirements for R-ADT and helps identify many of the additional specific requirements for such systems. The data elements described may not all be needed but, if used, they must be used in the way specified so that each record segment has comparable data. This guide will help answer questions faced by designers of R-ADT capabilities by providing a clear description of the consensus of health care professionals regarding a uniform set of minimum data elements used by R-ADT functions in each component of the larger system. It will also help educate health care professionals in the general principles of patient care information management as well as the details of the constituent specialty areas.
1.2 This standard does not purport to address the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use.
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An American National Standard
Designation:E1239–00
Standard Guide for
Description of Reservation/Registration-Admission,
Discharge, Transfer (R-ADT) Systems for Electronic Health
Record (EHR) Systems
This standard is issued under the fixed designation E1239; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision.Anumber in parentheses indicates the year of last reapproval.A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
1. Scope Computer-Based Patient Record Systems
E1633 Specification for Coded Values Used in Computer-
1.1 Thisguideidentifiestheminimuminformationcapabili-
based Patient Record Systems
ties needed by an ambulatory care system or a resident facility
E1639 Guide for Functional Requirements of Clinical
R-ADT system. This guide is intended to depict the processes
Laboratory Information Management Systems
of: patient registration, inpatient admission into health care
E1714 Guide for Properties of a Universal Health Identi-
institutions and the use of registration data in establishing and
fier
using the demographic segments of the electronic health
E1715 Practice for Object-Oriented Model for Registra-
record. It also identifies a common core of informational
tion, Admitting, Discharge, and Transfer (R-ADT) Func-
elements needed in this R-ADT process and outlines those
tions in Computer-Based Patient Record Systems
organizational elements that may use these segments. Further-
E1744 GuideforaViewofEmergencyMedicalCareinthe
more, this guide identifies the minimum general requirements
Computerized Medical Record
for R-ADT and helps identify many of the additional specific
E1869 GuideforConfidentiality,Privacy,Access,andData
requirements for such systems. The data elements described
Principles for Health Information Including Computer-
maynotallbeneededbut,ifused,theymustbeusedintheway
based Patient Records
specified so that each record segment has comparable data.
E2118 Guide for Coordination of Clinical Laboratory Ser-
This guide will help answer questions faced by designers of
vices within the Electronic Health Record Environment
R-ADT capabilities by providing a clear description of the
and Networked Architectures
consensus of health care professionals regarding a uniform set
2.2 ANSI Standards:
of minimum data elements used by R-ADT functions in each
ANSX3.38 Identification of States of the United States for
componentofthelargersystem.Itwillalsohelpeducatehealth
Information Interchange
care professionals in the general principles of patient care
ANSX3.47 Structure of the Identification of Name Popu-
information management as well as the details of the constitu-
lated Places and Related Entities of the States of the
ent specialty areas.
United States
1.2 This standard does not purport to address the safety
2.3 ISO Standards:
concerns, if any, associated with its use. It is the responsibility
ISO 639 Names of Languages
of the user of this standard to establish appropriate safety and
ISO 3166 Names of Countries
health practices and determine the applicability of regulatory
ISO 5218 Representation of Human Sexes
limitations prior to use.
2.4 Federal Information Processing Standard Publication:
2. Referenced Documents
FIPSPUB 6-2 Counties of the States of the United States
FIPSPUB 5-1 States of the United States
2.1 ASTM Standards:
E1238 Specification forTransferring Clinical Observations
3. Terminology
Between Independent Computer Systems
3.1 Definitions of Terms Specific to This Standard:
E1384 Guide for Description of Content and Structure of
3.1.1 admission—formal acceptance by a hospital of a
patientwhoistobeprovidedwithroom,board,andcontinuous
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.19 on Electronic
HealthRecordContentandStructure.Thisguidewaspreparedincollaborationwith Available fromAmerican National Standards Institute, 11 West 42nd St., 13th
the American Health Information Management Assn. floor, New York, NY 10036.
Current edition approved Nov. 10, 2000. Published January 2001. Originally Available from ISO.
published as E1239–88. Last previous edition E1239–94. Available from US Dept. of Commerce, Government Printing Office, Wash-
Annual Book of ASTM Standards, Vol 14.01. ington, DC.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
E1239–00
nursing services in an area of the hospital where patients 3.1.17 transfer—change in medical care unit, medical staff,
generally stay overnight. or responsible physician of an inpatient during hospitalization.
3.1.18 uniform hospital discharge data set—Thoseessential
3.1.2 basic data set for ambulatory care—data items which
dataelementswhichshouldberecordedtoprovideacomposite
constitutetheminimumbasicsetofdatathatshouldbeentered
picture of the patient’s stay.
in the record concerning all ambulatory medical care encoun-
3.2 Acronyms:Acronyms:
ters.
CPR Computer-based Patient Record
3.1.3 clinic outpatient—admitted to a clinical service of a
EHR Electronic Health Record
hospital for diagnosis or therapy on an ambulatory basis in a
R-ADT Registration-Admission, Discharge,
formally organized unit of a medical or surgical specialty or
Transfer
subspecialty.The clinic assumes overall medical responsibility
4. Significance and Use
for the patient.
3.1.4 discharge—termination of a period of inpatient hos- 4.1 Background:
pitalization through the formal release of the inpatient by the 4.1.1 Effective health care delivery requires an efficient
hospital. information base. A standard description is needed regarding
thecapabilitiesofRegistration-Admission,Discharge,Transfer
3.1.5 disposition—directing of a patient from one
(R-ADT) Systems in both automated hospital and ambulatory
environment/health care delivery mode to another at conclu-
care information systems. This guide is intended not only to
sion of services.
provide a common explanation of the minimum information
3.1.6 emergency patient—admitted to emergency room ser-
elements required in such systems, thus augmenting those
vice of a hospital for diagnosis and therapy of a condition that
,
already published but also to provide the basis for future
requires immediate medical, dental, or allied services.
patient data interchange formats. This guide has been devel-
3.1.7 encounter—face-to-facecontactbetweenapatientand
oped to serve as a uniform minimum description of R-ADT
a provider who has primary responsibility for assessing and
functional components that should be common in all systems
treating the patient at a given contact, exercising independent
and used in both transportable general purpose and custom
judgment.
developedsystems.Thisdescriptionrequiresacceptanceofthe
3.1.8 inpatient—an individual receiving, in person, resident
premise regarding the need for logical integration of concepts
hospital-based or coordinated medical services for which the
insystemsdevelopment.Intheintegratedsystemsconcept,the
hospital is responsible.
R-ADT function is the foundation module for all patient
3.1.9 inpatient episode—periodoftimeinwhichthepatient
information and communication among all departments, and it
is in an inpatient status, beginning with admission and termi-
is used in initiating services within the patient care setting. A
nating with discharge.
common R-ADT system in a hospital enables all departments
3.1.10 master patient index—permanent listing that reveals
to streamline the initiation and tracking of the services they
identityandlocationofpatientstreatedbyahealthcarefacility.
providetopatients;italsoprovidesanopportunityforaccurate
3.1.11 outpatient—an individual receiving, in person, non-
tracking of patient movement throughout a hospital stay, for
resident, provider-supplied or coordinated medical services for
instance,andthelinkageofinpatientandoutpatientservices.It
which the provider is responsible. The types of outpatients
is also the system which provides all inpatient census-related
recognized are:
administrative reports. Likewise, an R-ADT component in an
3.1.11.1 Emergency
EnterpriseArchitecturecapturestheinitialpatientdemographic
3.1.11.2 Clinic, and
profile for the EHR and is subsequently accessed in posting an
individual’s clinical data, for inquiry regarding that clinical
3.1.11.3 Referred.
dataandforlinkagetofinancialrecords.Itisanintegralpartof
3.1.12 patient care record—legal documented record of
theEHRfunction.Itmayalsobelinkedtoothersystemswhich
health care services provided by a health care facility. Synony-
provide patient care information management capabilities.
mous with: medical record, health record, patient record.
4.1.2 A registration system is capable of providing the
3.1.13 practitioner specialty—for a particular practitioner,
initialinformationcaptureforallhealthcarefacilities;anADT
the subject area of health care or scope of health care services
subsystem can provide common admitting data for all depart-
in which the major share of his or her practice is carried out.
ments in hospitals and other inpatient facilities. Establishing a
See National Provider System Taxonomy in Specification E
standard description of a logical R-ADT process model is
1633.
useful because that standard will become a reference for other
3.1.14 registration—recording the patient demographic and
documents describing the other functional subsystems used in
financialdatainaunitrecordforpatientcareorabillingrecord
patient care information systems. It is understood that a
for charge capture, respectively.
minimum set of information elements must be initially cap-
3.1.15 referred outpatient—admitted exclusively to a spe-
tured upon registration and then used for all subsequent
cialdiagnostic/therapeuticserviceofthehospitalfordiagnosis/
treatment on an ambulatory basis. Responsibility remains with
the referring physician.
Uniform Ambulatory Medical Care: Minimum Data Set,, DHHS Publication
3.1.16 specialty type—classificationofspecializedfieldsof
PHS 81-1161, DHHS National Center for Health Statistics, 1981.
medical services, such as, for example, Gynecology, General
Uniform Hospital Discharge Data Set, DHHS Publication HSM 74-1451,
Surgery, Orthopedic Surgery, etc. Health Information Policy Council DHHS, 1984.
E1239–00
ambulatory or inpatient care; the subsequent minimum set of 5.1.4 Augment the registration record by addition of those
admitting elements is then used to drive or initiate additional data required for any inpatient admission.
services for patients through each subsystem. With a standard
5.1.5 Initiate services for all patients admitted to the facility
minimum R-ADT component definition, standards for con- by providing notification of the start of services.
stituent subsystems can now be coordinated and developed
5.1.6 Track movements of the inpatient throughout hospi-
through reference to this model. This description should be
talization.
usedbyvendorsandsubsystemdesignerswhoneedtodevelop
5.1.7 Facilitate scheduling of ancillary and clinical services
their systems in a coordinated and integrated way so that each
through a bed control and transfer function.
subsystem will contribute modularly with overall systems
5.1.8 Produce the inpatient census data and the correspond-
planning for the user organization. Such modularity will aid
ing census and statistical reports.
management who are assigned to evaluate each system and
5.1.9 Identify movement, location, status, and discharge of
subsystem in order to assess the potential of existing technol-
each in-patient and the times and dates of these events, this
ogy to provide the needed patient care information manage-
helps coordinate efficient support services for treating that
ment systems capabilities.
patient during hospitalization. This is achieved by means of
4.2 Use—Thisguideiswrittenassumingthatthehealthcare
census reporting and afterwards during follow-up care by
facility will have several options for gaining the R-ADT
means of linkage to the care record.
capability and may either acquire a system from a commercial
5.1.10 Offer all departments of the health care facility
vendor or design an integrated in-house system which may be
common information about each registered/admitted patient
a component of an ambulatory care practice or a hospital
through maintenance of a single registration record, thus
information system. Many of the characteristics of existing
eliminating duplicative patient data capture by those depart-
vendor systems are conventional and can interoperate; the care
ments.
facility may simply need to identify whether or not the offered
5.1.11 Produce the initial portion of a uniform hospital
features meet its needs. Beyond the general capabilities, the
discharge abstract and the initial data set used for clinical and
unique systems capabilities can then be identified and struc-
financial analysis.
tured to meet the special needs of that individual enterprise.A
5.1.12 Identify the roles of all responsible practitioners for
more accurate selection can therefore be made from the
each patient.
features offered by vendors if each health care facility/hospital
5.2 Background—In the past, the functions comprising
carefully identifies its own R-ADT functional requirements
typical R-ADT system services have included:
withtheaidofthisguidepriortoevaluatingcandidatesystems
5.2.1 Provide a means to build, update, correct, and main-
or development approaches and specifying that these require-
tain an existing master patient index, or the current portion
ments be met.
thereof.
4.3 Role of R-ADT Systems in Integrated Delivery
5.2.2 Provide patient identification through a master patient
Systems—Registration/Reservation-Admission, Discharge.
index to identify all care recipients.
Transfer functions in integrated delivery systems need to
5.2.3 Maintain a registry of all patients who have received
provide a uniform enterprise view with data accessible across
care; the registration record on each patient should contain all
the IDS. Typical functions in this environment may include
general demographic data on the patient and identify member-
registration to an enterprise master patient index, reporting
shipinallspecialclassesofpatients,suchasoncology,cardiac,
capabilities on R-ADT functions, enterprise scheduling and
trauma, etc.
enterprise capabilities for eligibility and utilization manage-
5.2.4 Create admission lists for notification of hospital
ment. Patient data collected should be transferable to medical
departments including: nursing units, business offi
...
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