ASTM E1239-04(2010)
(Practice)Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems (Withdrawn 2017)
Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems (Withdrawn 2017)
SIGNIFICANCE AND USE
Background:
Effective health care delivery requires an efficient information base. A standard description is needed regarding the capabilities of Registration-Admission, Discharge, Transfer (R-ADT) Systems in both automated hospital and ambulatory care information systems. This practice is intended not only to provide a common explanation of the minimum information elements required in such systems, thus augmenting those already published , but also to provide the basis for future patient data interchange formats. This practice has been developed to serve as a uniform minimum description of R-ADT functional components that should be common in all systems and used in both transportable general purpose and custom developed systems. This description requires acceptance of the premise regarding the need for logical integration of concepts in systems development. In the integrated systems concept, the R-ADT function is the foundation module for all patient information and communication among all departments, and it is used in initiating services within the patient care setting. A common R-ADT system in a hospital enables all departments to streamline the initiation and tracking of the services they provide to patients; it also provides an opportunity for accurate tracking of patient movement throughout a hospital stay, for instance, and the linkage of inpatient and outpatient services. It is also the system which provides all inpatient census-related administrative reports. Likewise, an R-ADT component in an Enterprise Architecture captures the initial patient demographic profile for the EHR and is subsequently accessed in posting an individual's clinical data, for inquiry regarding that clinical data and for linkage to financial records. It is an integral part of the EHR function. It may also be linked to other systems which provide patient care information management capabilities.
A registration system is capable of providing the initial information capture for al...
SCOPE
1.1 This practice identifies the minimum information capabilities needed by an ambulatory care system or a resident facility R-ADT system. This practice 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 practice 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 all of 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 requirements prior to use.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this practice was withdrawn in March 2017. This standard is being withdrawn without replacement due to its limited use by industry.
General Information
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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: E1239 − 04 (Reapproved 2010) An American National Standard
Standard Practice 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 (´) indicates an editorial change since the last revision or reapproval.
1. Scope 2. Referenced Documents
2.1 ASTM Standards:
1.1 This practice identifies the minimum information capa-
E1384Practice for Content and Structure of the Electronic
bilities needed by an ambulatory care system or a resident
Health Record (EHR)
facility R-ADT system. This practice is intended to depict the
E1633SpecificationforCodedValuesUsedintheElectronic
processes of: patient registration, inpatient admission into
Health Record
health care institutions and the use of registration data in
E1714Guide for Properties of a Universal Healthcare Iden-
establishing and using the demographic segments of the
tifier (UHID)
electronic health record. It also identifies a common core of
E1715 Practice for An Object-Oriented Model for
informational elements needed in this R-ADT process and
Registration,Admitting, Discharge, and Transfer (RADT)
outlines those organizational elements that may use these
Functions in Computer-Based Patient Record Systems
segments. Furthermore, this guide identifies the minimum
E1869Guide for Confidentiality, Privacy, Access, and Data
general requirements for R-ADT and helps identify many of
SecurityPrinciplesforHealthInformationIncludingElec-
theadditionalspecificrequirementsforsuchsystems.Thedata
tronic Health Records
elements described may not all be needed but, if used, they
2.2 ANSI Standards:
must be used in the way specified so that each record segment
ANSX3.38Identification of States of the United States for
has comparable data. This practice will help answer questions
Information Interchange
faced by designers of R-ADT capabilities by providing a clear
ANSX3.47Structure of the Identification of Name Popu-
description of the consensus of health care professionals
lated Places and Related Entities of the States of the
regarding a uniform set of minimum data elements used by
United States
R-ADT functions in each component of the larger system. It NCCLSLIS-5ASpecification for Transferring Clinical Ob-
will also help educate health care professionals in the general servations Between Independent Computer Systems
NCCLS LIS-8A Guide for Functional Requirements of
principles of patient care information management as well as
Clinical Laboratory Information Management Systems
the details of the constituent specialty areas.
NCCLSLIS-9AGuide for Coordination of Clinical Labora-
1.2 This standard does not purport to address all of the
tory Services within the Electronic Health Record Envi-
safety concerns, if any, associated with its use. It is the
ronment and Networked Architectures
responsibility of the user of this standard to establish appro- 4
2.3 ISO Standards:
priate safety and health practices and determine the applica-
ISO 639Names of Languages
bility of regulatory requirements prior to use.
ISO 3166Names of Countries
ISO 5218Representation of Human Sexes
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare Standards volume information, refer to the standard’s Document Summary page on
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare the ASTM website.
Data Management, Security, Confidentiality, and Privacy. This guide was prepared Available fromAmerican National Standards Institute (ANSI), 25 W. 43rd St.,
in collaboration with the American Health Information Management Assn. 4th Floor, New York, NY 10036, http://www.ansi.org.
Current edition approved March 1, 2010. Published August 2010. Originally Available from International Organization for Standardization (ISO), 1, ch. de
approved in 1988. Last previous edition approved in 2004 as E1239–04. DOI: la Voie-Creuse, Case postale 56, CH-1211, Geneva 20, Switzerland, http://
10.1520/E1239-04R10. www.iso.ch.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
E1239 − 04 (2010)
2.4 Federal Information Processing Standard Publication: in which the major share of his or her practice is carried out.
FIPSPUB 6-2Counties of the States of the United States See National Provider System Taxonomy in Specification
FIPSPUB 5-1States of the United States E1633.
3.1.14 registration—recording the patient demographic and
3. Terminology
financialdatainaunitrecordforpatientcareorabillingrecord
3.1 Definitions of Terms Specific to This Standard:
for charge capture, respectively.
3.1.1 admission—formal acceptance by a hospital of a
3.1.15 referred outpatient—admitted exclusively to a spe-
patientwhoistobeprovidedwithroom,board,andcontinuous
cialdiagnostic/therapeuticserviceofthehospitalfordiagnosis/
nursing services in an area of the hospital where patients
treatment on an ambulatory basis. Responsibility remains with
generally stay overnight.
the referring physician.
3.1.2 basic data set for ambulatory care—data items which
3.1.16 specialty type—classification of specialized fields of
constitutetheminimumbasicsetofdatathatshouldbeentered
medical services, such as, for example, Gynecology, General
in the record concerning all ambulatory medical care encoun-
Surgery, Orthopedic Surgery, etc.
ters.
3.1.17 transfer—change in medical care unit, medical staff,
3.1.3 clinic outpatient—admitted to a clinical service of a
or responsible physician of an inpatient during hospitalization.
hospital for diagnosis or therapy on an ambulatory basis in a
3.1.18 uniform hospital discharge data set—Thoseessential
formally organized unit of a medical or surgical specialty or
dataelementswhichshouldberecordedtoprovideacomposite
subspecialty.The clinic assumes overall medical responsibility
picture of the patient’s stay.
for the patient.
3.2 Acronyms:
3.1.4 discharge—termination of a period of inpatient hospi-
CPR Computer-based Patient Record
talization through the formal release of the inpatient by the
EHR Electronic Health Record
hospital.
R-ADT Registration-Admission, Discharge, Transfer
ADT Admittng, Discharge, Transfer
3.1.5 disposition—directing of a patient from one
R-RADT Registration/Reservation-Admitting, Discharge,Transfer
environment/health care delivery mode to another at conclu-
MPI Master Patient/Person Index
sion of services.
4. Significance and Use
3.1.6 emergency patient—admitted to emergency room ser-
vice of a hospital for diagnosis and therapy of a condition that
4.1 Background:
requires immediate medical, dental, or allied services.
4.1.1 Effective health care delivery requires an efficient
information base. A standard description is needed regarding
3.1.7 encounter—face-to-facecontactbetweenapatientand
thecapabilitiesofRegistration-Admission,Discharge,Transfer
a provider who has primary responsibility for assessing and
(R-ADT) Systems in both automated hospital and ambulatory
treating the patient at a given contact, exercising independent
care information systems. This practice is intended not only to
judgment.
provide a common explanation of the minimum information
3.1.8 inpatient—an individual receiving, in person, resident
elements required in such systems, thus augmenting those
hospital-based or coordinated medical services for which the
6,7
already published but also to provide the basis for future
hospital is responsible.
patient data interchange formats.This practice has been devel-
3.1.9 inpatient episode—period of time in which the patient
oped to serve as a uniform minimum description of R-ADT
is in an inpatient status, beginning with admission and termi-
functional components that should be common in all systems
nating with discharge.
and used in both transportable general purpose and custom
3.1.10 master patient index—permanent listing that reveals developedsystems.Thisdescriptionrequiresacceptanceofthe
identityandlocationofpatientstreatedbyahealthcarefacility.
premise regarding the need for logical integration of concepts
insystemsdevelopment.Intheintegratedsystemsconcept,the
3.1.11 outpatient—an individual receiving, in person, non-
R-ADT function is the foundation module for all patient
resident, provider-supplied or coordinated medical services for
information and communication among all departments, and it
which the provider is responsible. The types of outpatients
is used in initiating services within the patient care setting. A
recognized are:
common R-ADT system in a hospital enables all departments
3.1.11.1 Emergency
to streamline the initiation and tracking of the services they
3.1.11.2 Clinic, and
providetopatients;italsoprovidesanopportunityforaccurate
3.1.11.3 Referred.
tracking of patient movement throughout a hospital stay, for
3.1.12 patient care record—legal documented record of
instance,andthelinkageofinpatientandoutpatientservices.It
healthcareservicesprovidedbyahealthcarefacility.Synony-
is also the system which provides all inpatient census-related
mous with: medical record, health record, patient record.
administrative reports. Likewise, an R-ADT component in an
3.1.13 practitioner specialty—for a particular practitioner,
the subject area of health care or scope of health care services
Uniform Ambulatory Medical Care: Minimum Data Set,, DHHS Publication
PHS 81-1161, DHHS National Center for Health Statistics, 1981.
5 7
Available from US Dept. of Commerce, Government Printing Office, Uniform Hospital Discharge Data Set, DHHS Publication HSM 74-1451,
Washington, DC. Health Information Policy Council DHHS, 1984.
E1239 − 04 (2010)
EnterpriseArchitecturecapturestheinitialpatientdemographic tronic health records. IDS networks provide infrastructure and
profile for the EHR and is subsequently accessed in posting an should conform to enterprise technical security requirements
individual’s clinical data, for inquiry regarding that clinical that meet legal and accreditation requirements.
dataandforlinkagetofinancialrecords.Itisanintegralpartof
theEHRfunction.Itmayalsobelinkedtoothersystemswhich
5. System Description
provide patient care information management capabilities.
5.1 General Principles and Purpose—The purposes of an
4.1.2 A registration system is capable of providing the
R-ADT system are to:
initialinformationcaptureforallhealthcarefacilities;anADT
5.1.1 Identifyorverifypatients,orboth,viaafacilitymaster
subsystem can provide common admitting data for all depart-
patient index created and maintained through the registration
ments in hospitals and other inpatient facilities. Establishing a
process.
standard description of a logical R-ADT process model is
5.1.2 Establish an initial record of the patient entry into the
useful because that standard will become a reference for other
system by creating the demographic segment of the EHR
documents describing the other functional subsystems used in
(registration).
patient care information systems. It is understood that a
5.1.3 Maintaintheregistrationrecordanddemographicdata
minimum set of information elements must be initially cap-
asacommonnodeforpatientcarerecordsystemssothatitcan
tured upon registration and then used for all subsequent
be used by all ancillary support systems.
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 inpatients admitted to the
minimum R-ADT component definition, standards for con-
facility 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
census reporting and afterwards during follow-up care by
4.2 Use—This practice is written assuming that the health
care facility will have several options for gaining the R-ADT means of linkage to the care record.
5.1.10 Offer all departments of the health care facility
capability and may either acquire a system from a commercial
vendor or design an integrated in-house system which may be common information about each registered/admitted patient
through maintenance of a single registration record, thus
a component of an ambulatory care practice or a hospital
information system. Many of the characteristics of existing eliminating duplicative patient data capture by those depart-
ments.
vendorsystemsareconventionalandcaninteroperate;thecare
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—Inthepast,thefunctionscomprisingtypi-
carefully identifies its own R-ADT functional requirements
cal R-ADT system services have included:
withtheaidofthisguidepriortoe
...
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