Standard Guide for Amendments to Health Information

SCOPE
1.1 This guide addresses the criteria for amending individually-identifiable health information. Certain criteria for amending health information is found in federal and state laws, rules and regulations, and in ethical statements of professional conduct. Although there are several sources for guidance, there is no current national standard on this topic.

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Status
Historical
Publication Date
09-May-1999
Current Stage
Ref Project

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ASTM E2017-99(2005) - Standard Guide for Amendments to Health Information
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NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
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An American National Standard
Designation:E2017–99 (Reapproved 2005)
Standard Guide for
1
Amendments to Health Information
This standard is issued under the fixed designation E2017; 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 information, which is entrusted to another with the confidence
that unauthorized disclosure that will be prejudicial to the
1.1 This guide addresses the criteria for amending
individual will not occur. (E1869)
individually-identifiablehealthinformation.Certaincriteriafor
3.1.6 delete, v—(1) to eliminate by blotting out, cutting out
amending health information is found in federal and state laws,
or erasing; (2) to remove or eliminate, as to erase data from a
rules and regulations, and in ethical statements of professional
field or to eliminate a record from a file, a method of erasing
conduct.Although there are several sources for guidance, there
data. (Webster’s 1993, Webster’s New World Dictionary
is no current national standard on this topic.
of Computer Terms, 1994)
2. Referenced Documents
3.1.7 error, n—act involving an unintentional deviation
2
from truth or accuracy.
2.1 ASTM Standards:
3.1.8 health information, n—any information, whether oral
E1762 Guide for Electronic Authentication of Health Care
or recorded, in any form or medium (1) that is created or
Information
received by a health care practitioner; a health plan; health
E1869 Guide for Confidentiality, Privacy,Access, and Data
researcher, public health authority, instructor, employer, school
Security Principles for Health Information Including Elec-
or university, health information service or other entity that
tronic Health Records
creates, receives, obtains, maintains, uses or transmits health
3. Terminology
information; a health oversight agency, a health information
service organization, or (2) that relates to the past, present, or
3.1 Definitions:
future physical or mental health or condition of an individual,
3.1.1 amendment, n—alteration of health information by
theprovisionofhealthcaretoanindividual,orthepast,present
modification, correction, addition, or deletion.
or future payments for the provision of health care to a
3.1.2 authentication, n—provision of assurance of the
protected individual; and, (3) that identifies the individual with
claimed identity of an entity, receiver, or object.
3
respect to which there is a reasonable basis to believe that the
(E1869, E1762, CPRI )
information can be used to identify the individual.
3.1.3 author, n—person(s) who is (are) responsible and
4
(HIPAA , E1869)
accountable for the health information creation, content, accu-
3.1.9 information, n—data to which meaning is assigned,
racy, and completeness for each documented event or health
according to context and assumed conventions
record entry.
(E1869)
3.1.4 commission, n—act of doing, performing, or commit-
3.1.10 omission, n—somethingneglectedorleftundone,the
ting something. (Webster’s 1993)
act of omitting. (Webster’s 1993)
3.1.5 confidential, adj—(1) status accorded to data or infor-
3.1.11 permanence, n—quality of being in a constant, con-
mation indicating that it is sensitive for some reason and needs
tinuous state.
to be protected against theft, disclosure, or improper use, or all
three, and must be disseminated only to authorized individuals
4. Significance and Use
or organizations with an approved need to know; (2) private
4.1 The purpose of this guide is to assure comparability
between paper-based and computer-based amendments. Paper-
1
based and computer-based amendments must have comparable
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
methods, practices and policies, in order to assure an unam-
Management, Security, Confidentiality, and Privacy.
biguous representation of the sequence and timing of docu-
Current edition approved May 10, 1999. Published September 1999. DOI:
mented events. Original and amended health information
10.1520/E2017-99R05.
2
For referenced ASTM standards, visit the ASTM website, www.astm.org, or entries and documents must both be displayed and must be
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website.
3 4
CPRI (Computer-Based Record Institute), 4915 Saint Elmo Ave., Suite 401, HIPAA (Health Insurance Portability and Accountability Act), 1996 (http://
Bethesda, MD 20814 (http://www.cpri.org). www.hcfa.gov/hipaa/hipaahm.htm).
Copyright © ASTM Internati
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