ASTM E1633-08a(2013)
(Specification)Standard Specification for Coded Values Used in the Electronic Health Record
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
4.1 Purpose—The approval of Guide E1384, 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 E1384 now provides a means of cataloging the value sets representing each data element (see Guide E1384). Specification E1238, coordinated with Guide E1239, describes conventions for representing many of the data values for data elements that are included in the more comprehensive listing in Guide E1384. A comprehensive listing of all of the value sets associated with Guide E1384 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.
4.2 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...
SCOPE
1.1 This specification covers the identification of the lexicons to be used for the data elements identified in Appendix X1 of Guide E1384. 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
Relations
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(Reapproved 2013) An American National Standard
Standard Specification for
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.
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
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
2.1 ASTM Standards:
E1238 Specification for Transferring Clinical Observations
4. Significance and Use
Between Independent Computer Systems (Withdrawn
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
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
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 April 15, 2013. Published April 2013. Originally
introduces systematics and consistency into the representation.
approved in 1996. Last previous edition approved in 2008 as E1633–08a. DOI:
The catalog must establish both a global framework consistent
10.1520/E1633-08AR13.
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 service@astm.org. 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.
The last approved version of this historical standard is referenced on
www.astm.org.
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 C700, West Conshohocken, PA 19428-2959. United States
E1633−08a (2013)
from many organizations, including government agencies and
09001.12 Body System/Region (5.2.22)
09001.13 Exam Finding (5.2.77)
other standards bodies and professional associations, and as a
09001.30 Tooth ID (5.2.74)
result of the effort to achieve consistency and comprehensive-
09001.30.05 Tooth Surface (5.2.75)
ness among the data dealt with by various standards efforts.
09001.30.06 Tooth Sensitivity Code (5.2.65)
09001.30.07 Tooth Mobility Code (5.2.66)
4.2 General Values—Earlyinthecoordinationofhealthcare
09001.40.1 Prosthesis Type (5.2.67)
11001.01.24 Test Specimen Source (5.2.68)
information standards an informal body, the Healthcare Infor-
14001.A002 Patient (Encounter) Type/Admission Source (5.2.17)
mationStandardsCoordinatingCommittee(HISCC),identified
14001.A004 Confidentiality Status (5.2.1)
certain common data element types and agreed upon conven-
14001.A010 Encounter Status (5.2.69)
tions for representing these data element types in a standard 14001.A013 Facility Care/Healthcare setting (5.2.18)
14001.A016 Reason for Visit (5.2.19)
manner.Thissetthestageforthedevelopmentofthevaluesets
14001.A020 Encounter patient Arrival Condition (5.2.70)
for the CODED VALUE data type. The status of the standard
14001.A021 Mode of Arrival (5.2.29)
14001.A030 Nature of Injury (5.2.30)
noncoded data types, and their representations, agreed upon by
14001.A033 Mode of Injury (5.2.31)
the HISCC are:
14001.A034 Product of Injury (5.2.37)
4.2.1 Person Names— Specification E1238, Guide E1239,
14001.A040 Injury On the Job Status (5.2.71)
14001.A044 Protective Equipment Used (5.2.32)
Practice E1715, Practice E1744, and HL-7 use the same
14001.A063 Patient Admission Type (5.2.12)
representation for American and European forms.
14001.A110 Professional Specialty (5.2.16)
4.2.2 Addresses—Common format in Specification E1238,
14001.A133 Accommodation type (5.2.15)
14001.A163.01 Patient In-residence Transfer Type (5.2.13)
Guide E1239, Practice E1715, and Practice E1744. E1239.
14001.A170 Diagnosis (5.2.33)
4.2.3 Telephone Numbers—Specification E1238 and Guide
14001.A170.01 Diagnosis Type (5.2.34)
E1239 currently use the same representation with area code
14001.A170.02 Diagnosis Status Code (5.2.35)
14001.A186.01 Current Clinical Status (5.2.36)
enclosed in parentheses and country code preceding the paren-
14001.A206 Police Hold Status (5.2.72)
theses.
14001.A213 Medical Examiner Notification Code (5.2.73)
4.2.4 Dates—Date and time represented as ANS X3.51-
14001.A223 Source of Payment Code (5.2.21)
14001.F050 Discharge Disposition Category (5.2.14)
1986/ISO 8601-1988 with years in four digits; time not
separated from date by “T” as permitted by ISO 8601. This standard identifies the current value list for each of
4.2.5 Numbers—Numbers are represented either as integers these elements as of the approval date of this standard (see
or fixed point numbers; exponential notation not presently footnote 1) and states the evolving status of this catalog as the
accepted in Specification E1238, Guide E1239, or HL-7. Units knowledge of the use of these elements expands as a result of
of Measure by ISO 2955-1983 or ANS X3.50-86. ongoing investigation. Each element is identified by the index
4.2.6 Strings—7-bit ASCII characters; multilingual charac- assigned to it in the revised Appendix X1 of Guide E1384.
ter sets not yet defined. Moreover, the definition for that element from the Data
Element Catalog (1) is included with the value set.
5. Assignment of Coded Values
5.2 Value Set Tables—Thesetablescollecttherepresentation
5.1 The major important data elements in Guide E1384
of coded data values for specific data elements in computer-
havingcodeddatatypesandthecurrentstatusofthecataloging
based patient record structures identified in Appendix X1 of
of their values are:
Guide E1384. The terms listed here are the minimal essential
01035 Patient Multiple Birth code (5.2.23) ones but may be further subclassified to include more specific
01040 Sex (5.2.20)
terms by appropriate extensions of the included terms.
01042 Biogeographic Ancestry (Race) (5.2.3)
5.2.1 Confidentiality Status—This data element, Index:
01045 Ethnicity (5.2.4)
01047 Religion (5.2.7)
14001.A004, contains the minimal commonly used values
01052 Marital status (5.2.2)
appearing in both manual and automated systems. See Speci-
01055 Nationality/Country of Origin (5.2.6)
fication E1238.
01057 Language (5.2.5)
01060 Educational Level (5.2.8)
Unwed mother UWM
Educational Certification (5.2.9)
Celebrity VIP
01062 Current Work Status (5.2.24)
Psychiatric patient PSY
01065 Occupation (5.2.11) also 01070,01090.03
Employee EMP
01067 Current Vocational Status (5.2.25)
AIDS patient AID
01085 Usual Living arrangement (5.2.26)
HIV patient HIV
01099 Foreign Residency Code (5.2.27)
Alcohol/Drug patient ETH
01090.03 Family Relationship (5.2.10)
Usual control U
01155 Color Eyes (5.2.38)
Restricted R
01160 Color Hair (5.2.39)
Very restricted V
01175 Body Build for Identification (5.2.40)
02052 Durable Power of Attorney Status (5.2.28) 5.2.2 Marital Status—This data element, Index: 01052,
06001.01.15 Immunization reaction/result (5.2.63)
encompasses the values noted by Westermeyer (2), Bureau of
04001.50 Professional Specialty (5.2.16)
Census, the VA DHCP system, the DoD CHCS system, the
08005 Birth method (5.2.64)
08095 Health History Response (5.2.76) X12 835 Transaction Set (3) , UB-82 (4), and used in common
practice.
Never married B
Single S
The boldface numbers in parentheses refer to the list of references at the end of
Married M
this standard.
E1633−08a (2013)
Divorced D AFRICA:CENTRALSUB- 0219-
Divorced/annulled L SAHARAN AFRICA
Divorced/separated H AFRICA:EAST AFRICA 0220-
Annulled N AFRICA:SOUTHERN AFRICA 0221-
Widowed W
Separated, NOS A AMERICA:NOS 1002-5 AMERICAN INDIAN/
Separated, legal E ALASKA NATIVE
Separated, nonlegal K AMERICA:NORTH AMERICA 0222-
Marriage, separation, temporary absence X (ABORIGINAL)
Marriage, separation, permanent absence V AMERICA:CENTRALAMERICA/ 0223-
Consensual union J CARIBBEAN (ABORIGINAL)
AMERICA:SOUTH AMERICA 0224-
Unknown U
Common Law C
EAST ASIA:NOS 2028-9 ASIAN
Domestic Partner P
Registered Domestic Partner R EAST ASIA:CENTRALASIA 0225-
EAST ASIA:NORTHERN ASIA 0226-
Living together G
Interlocutory I EAST ASIA:EAST ASIA 0227-
Other O EAST ASIA:SOUTH ASIA 0228-
Unreported T EAST ASIA:SOUTHEAST ASIA 0229-
EAST ASIA:AUSTRALIA (ABORIGINAL) 0230-
5.2.3 Biogeographic Ancestry (previously stated as:
Race)——This data element, Index: 01042, indicates the re- EURASIA:NOS 2106-3 WHITE
EURASIA:WESTERN EUROPE 0231-
gion of the world from which the patient’s ancestors came.
EURASIA:NORTHERN EUROPE 0232-
This is a biologic attribute that very generally indicates
EURASIA:EASTERN EUROPE 0233-
possible biologic diversity to which the patient might be EURASIA:SOUTHERN EUROPE/ 0234-
MEDITERANIAN
subject. Due to ambiguity inherent in the diversity of the large
EURASIA:NORTH AFRICA 0235-
number of inherited attributes which might characterize such
EURASIA:NEAR EAST 0236-
ancestry,otherdataelementsofthecarerecordwillberequired EURASIA:ARABIAN PENINSULA 0237-
EURASIA:WESTERN EURASIA 0238-
to assign full meaning to the value set recorded for this
attribute. The name originates from recommendations in the
OCEANIA:NOS 2076-8 HAWAIIAN/
PACIFIC ISLANDER
genetics literature (Am J Hum Gent 77:519-532 2005).
OCEANIA:PACIFIC ISLANDS 0239-
Therefore, utilization of these other attributes is strongly
recommended.Tobeconsistentwithcensusdata,thesixvalues
OTHER 2131-3
currently given in OMB Directive 15 are shown for relation-
5.2.4 Ethnicity—In keeping with current demographic
ship to the recommended new terms. New subcategories may
practice, this data element, Index: 01045, reflects the ethnic
be added as recommended by the genetics professional disci-
cultural group with which the patient identifies. Multiple
plines. The check digit for the code is calculated via program
selections may be made. Each value has associated with it an
previously given in Specification E1238 and shown in Appen-
ancestralculturalorigintagthatismostcloselyassociatedwith
dix X1. Note that NOS in the term means “Not Otherwise
the ancestral geographic origin of that cultural pattern.This tag
Specified.”
does not signify the ancestral biologic characteristics of the
Proposed Term Code Present Term
individual which is recorded in other data elements of the
AFRICA:NOS 2054-5 BLACK
record. See Fig. 1.
AFRICA:WEST AFRICA 0218-
E1633−08a (2013)
FIG. 1Ethnic Group
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
E1633−08a (2013)
FIG. 1Ethnic Group (continued)
...
Questions, Comments and Discussion
Ask us and Technical Secretary will try to provide an answer. You can facilitate discussion about the standard in here.