ASTM E1633-08a

Standard Specification for Coded Values Used in the Electronic Health Record

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
Purpose—The approval of Guide E 1384, 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 E 1384 now provides a means of cataloging the value sets representing each data element (see Guide E 1384). Specification E 1238, coordinated with Guide E 1239, describes conventions for representing many of the data values for data elements that are included in the more comprehensive listing in Guide E 1384. A comprehensive listing of all of the value sets associated with Guide E 1384 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.
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 f...
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: 14-Jul-2008
• 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 E1633-08 - Standard Specification for Coded Values Used in the Electronic Health Record
• Effective Date: 15-Jul-2008
• Replaced By: 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
Designation:E1633 −08a AnAmerican National Standard
Standard Specification for
1
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.
4
1. Scope* 2.3 ISO Standards:
ISO 639 Names of Languages
1.1 This specification covers the identification of the lexi-
ISO 2955 Representation of SI Units
constobeusedforthedataelementsidentifiedinAppendixX1
ISO 3166 Names of Countries
of Guide E1384. It is intended to unify the representations for:
ISO 5218 Representation of Human Sexes
(1) primary record of care data elements, (2) the data elements
ISO 8601 Representation Dates
identified in other standard statistical data sets, (3) data
2.4 Other Standards:
elements used in other healthcare data message exchange
5
HL-7 Health Industry Level 7 Interface Standards
format standards, or (4) in data gathering forms for this
purpose, and (5) in data derived from these elements in order
3. Terminology
thatdatarecordedinthecourseofpatientcarebeexchangeable
3.1 Acronyms:
and be the source of accurate statistical and resource manage-
3.1.1 NCHS—National Center for Health Statistics
ment data. This specification is applicable to all paper and
automated systems.
3.1.2 NCVHS—National Committee for Vital and Health
Statistics
2. Referenced Documents
3.1.3 NOS—not otherwise specified
2
2.1 ASTM Standards:
E1238 Specification for Transferring Clinical Observations
4. Significance and Use
Between Independent Computer Systems (Withdrawn
3
4.1 Purpose—The approval of Guide E1384, concerned
2002)
with the structure and content of the computer-based patient
E1239 Practice for Description of Reservation/Registration-
record, now includes a formal indexing of data elements and a
Admission, Discharge, Transfer (R-ADT) Systems for
cataloging of the minimal essential value set for these ele-
Electronic Health Record (EHR) Systems
ments. Indexing of these data elements with a unique identifier
E1384 Practice for Content and Structure of the Electronic
keyed to its position in the logical structure ofAppendix X1 of
Health Record (EHR)
Guide E1384 now provides a means of cataloging the value
E1715 Practice for An Object-Oriented Model for
sets representing each data element (see Guide E1384). Speci-
Registration,Admitting, Discharge, and Transfer (RADT)
fication E1238, coordinated with Guide E1239, describes
Functions in Computer-Based Patient Record Systems
conventions for representing many of the data values for data
E1744 Practice for View of Emergency Medical Care in the
elementsthatareincludedinthemorecomprehensivelistingin
Electronic Health Record
4
Guide E1384. A comprehensive listing of all of the value sets
2.2 ANSI Standards:
associated with Guide E1384 has not yet been assembled. This
ANS X3.50 Representation of Date and Time
specification begins to catalog the representation conventions
ANS X3.51 Representation of Common Units
for a number of these elements and in particular to list the
coded values. It is important that this catalog consider the
1
This specification is under the jurisdiction of ASTM Committee E31 on
traditionally assigned representations for each of these
Healthcare Informatics and is the direct responsibility of Subcommittee E31.25 on
Healthcare Data Management, Security, Confidentiality, and Privacy.
elements, and it must resolve differences in a manner that
Current edition approved July 15, 2008. Published August 2008. Originally
introduces systematics and consistency into the representation.
approved in 1996. Last previous edition approved in 2008 as E1633–08. DOI:
The catalog must establish both a global framework consistent
10.1520/E1633-08A.
2
For referenced ASTM standards, visit the ASTM website, www.astm.org, or with international standardization and with long-term growth,
contact ASTM Customer Service at [e-mail]. For Annual Book of ASTM
while at the same time maximizing familiar or traditional
Standards volume information, refer to the standard’s Document Summary page on
representations. This standard has been developed with input
the ASTM website.
3
The last approved version of this historical standard is referenced on
www.astm.org.
5
4
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 C7
...

This document is not anASTM standard and is intended only to provide the user of anASTM standard an indication of what changes have been made to the previous version. Because
it may not be technically possible to adequately depict all changes accurately, ASTM recommends that users consult prior editions as appropriate. In all cases only the current version
of the standard as published by ASTM is to be considered the official document.
An American National Standard
Designation:E1633–08 Designation: E 1633 – 08a
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 (´) indicates an editorial change since the last revision or reapproval.
1. 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
identifiedinotherstandardstatisticaldatasets,(3)dataelementsusedinotherhealthcaredatamessageexchangeformatstandards,
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.
2. Referenced Documents
2
2.1 ASTM Standards:
E 1238 Specification for Transferring Clinical Observations Between Independent Computer Systems
E 1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic
Health Record (EHR) Systems
E 1384 Practice for Content and Structure of the Electronic Health Record (EHR)
E 1715 Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in
Computer-Based Patient Record Systems
E 1744 Practice for View of Emergency Medical Care in the Electronic Health Record
3
2.2 ANSI Standards:
ANS X3.50 Representation of Date and Time
ANS X3.51 Representation of Common Units
3
2.3 ISO Standards:
ISO 639 Names of Languages
ISO 2955 Representation of SI Units
ISO 3166 Names of Countries
ISO 5218 Representation of Human Sexes
ISO 8601 Representation Dates
2.4 Other Standards:
4
HL-7 Health Industry Level 7 Interface Standards
3. Terminology
3.1 Acronyms: Acronyms:
3.1.1 NCHS—National Center for Health Statistics
3.1.2 NCVHS—National Committee for Vital and Health Statistics
3.1.3 NOS—not otherwise specified
4. Significance and Use
4.1 Purpose—The approval of Guide E 1384, 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 ofAppendix X1 of Guide E 1384 now
1
This specification is under the jurisdiction of ASTM Committee E31 on Healthcare Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
Data Management, Security, Confidentiality, and Privacy.
Current edition approved July 15, 2008. Published August 2008. Originally approved in 1996. Last previous edition approved in 20072008 as E 1633–078.
2
For referencedASTM standards, visit theASTM website, www.astm.org, or contactASTM 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.
3
Available from American National Standards Institute (ANSI), 25 W. 43rd St., 4th Floor, New York, NY 10036, http://www.ansi.org.
4
Available from Health Level 7, Mark McDougall, Executive Director, 900 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.
1

---------------------- Page: 1 ----------------------
E 1633 – 08a
provides a means of cataloging the value sets representing each data element (see Guide E 1384). Specification E 1238,
coordinated with Guide E 1239, describes conventions for representing many of the data values for data elements that are included
in the more comprehensive listing in Guide E 1384.Acomprehensive listing of all of the value sets associated with Guide E 1384
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 differen
...