ASTM E1633-02
(Specification)Standard Specification for Coded Values Used in the Electronic Health Record
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.
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Standards Content (Sample)
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An American National Standard
Designation: E 1633 – 02
Standard Specification for
1
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:
4
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: 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
cataloging of the minimal essential value set for these ele-
2. Referenced Documents
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)
2 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
2 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
3 each of these elements, and it must resolve differences in a
2.2 ANSI Standards:
manner that introduces systematics and consistency into the
ANS X3.50 Representation of Date and Time
representation. The catalog must establish both a global frame-
ANS X3.51 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.
1
This specification is under the jurisdiction of ASTM Committee E31 on
4.2 General Values—Early in the coordination of healthcare
Healthcare Informatics and is the direct responsibility of Subcommittee E31.19 on
information standards an informal body, the Healthcare Infor-
Electronic Health Record Content and Structure.
Current edition approved Jan. 10, 2002. Published March 2002. Originally
mation Standards Coordinating Committee (HISCC), identified
published as E 1633–96. Last previous edition E 1633–00.
2
Annual Book of ASTM Standards, Vol 14.01.
3 4
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