ASTM E1633 - 08A(2013)e1 Standard Specification for Coded Values Used in the Electronic Health Record (Withdrawn 2017).pdf

1、Designation: E1633 08a (Reapproved 2013)1An American National StandardStandard Specification forCoded Values Used in the Electronic Health Record1This standard is issued under the fixed designation E1633; the number immediately following the designation indicates the year oforiginal adoption or, in

2、the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1NOTEFigures reformatted as tables editorially in March 2015.1. Scope*1.1 This specification cov

3、ers the identification of the lexi-cons to be used for the data elements identified inAppendix X1of Guide E1384. It is intended to unify the representations for:(1) primary record of care data elements, (2) the data elementsidentified in other standard statistical data sets, (3) dataelements used in

4、 other healthcare data message exchangeformat standards, or (4) in data gathering forms for thispurpose, and (5) in data derived from these elements in orderthat data recorded in the course of patient care be exchangeableand be the source of accurate statistical and resource manage-ment data. This s

5、pecification is applicable to all paper andautomated systems.2. Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) SystemsE1384 Practice for Content and Structure of the E

6、lectronicHealth Record (EHR)E1715 Practice for An Object-Oriented Model forRegistration, Admitting, Discharge, and Transfer (RADT)Functions in Computer-Based Patient Record SystemsE1744 Practice for View of Emergency Medical Care in theElectronic Health Record2.2 ANSI Standards:3ANS X3.50 Representa

7、tion of Date and TimeANS X3.51 Representation of Common Units2.3 ISO Standards:3ISO 639 Names of LanguagesISO 2955 Representation of SI UnitsISO 3166 Names of CountriesISO 5218 Representation of Human SexesISO 8601 Representation Dates2.4 Other Standards:HL-7 Health Industry Level 7 Interface Standa

8、rds43. Terminology3.1 Acronyms:3.1.1 NCHSNational Center for Health Statistics3.1.2 NCVHSNational Committee for Vital and HealthStatistics3.1.3 NOSnot otherwise specified4. Significance and Use4.1 PurposeThe approval of Guide E1384, concernedwith the structure and content of the computer-based patie

9、ntrecord, now includes a formal indexing of data elements and acataloging of the minimal essential value set for these ele-ments. Indexing of these data elements with a unique identifierkeyed to its position in the logical structure of Appendix X1 ofGuide E1384 now provides a means of cataloging the

10、 valuesets representing each data element (see Guide E1384). GuideE1239 describes conventions for representing many of the datavalues for data elements that are included in the more compre-hensive listing in Guide E1384. A comprehensive listing of allof the value sets associated with Guide E1384 has

11、 not yet beenassembled. This specification begins to catalog the representa-tion conventions for a number of these elements and inparticular to list the coded values. It is important that thiscatalog consider the traditionally assigned representations foreach of these elements, and it must resolve d

12、ifferences in amanner that introduces systematics and consistency into therepresentation. The catalog must establish both a global frame-work consistent with international standardization and withlong-term growth, while at the same time maximizing familiaror traditional representations. This standar

13、d has been devel-oped with input from many organizations, including govern-ment agencies and other standards bodies and professional1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data M

14、anagement, Security, Confidentiality, and Privacy.Current edition approved April 15, 2013. Published April 2013. Originallyapproved in 1996. Last previous edition approved in 2008 as E163308a. DOI:10.1520/E1633-08AR13.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact AS

15、TM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.4Available from

16、Health Level 7, Mark McDougall, Executive Director, 900Victors Way, Suite 122, Ann Arbor, MI 48108.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United StatesNOTICE: This standard h

17、as either been superseded and replaced by a new version or withdrawn.Contact ASTM International (www.astm.org) for the latest information1associations, and as a result of the effort to achieve consistencyand comprehensiveness among the data dealt with by variousstandards efforts.4.2 General Values E

18、arly in the coordination of healthcareinformation standards an informal body, the Healthcare Infor-mation Standards Coordinating Committee (HISCC), identifiedcertain common data element types and agreed upon conven-tions for representing these data element types in a standardmanner. This set the sta

19、ge for the development of the value setsfor the CODED VALUE data type. The status of the standardnoncoded data types, and their representations, agreed upon bythe HISCC are:4.2.1 Person Names Guide E1239, Practice E1715, Prac-tice E1744, and HL-7 use the same representation for Ameri-can and Europea

20、n forms.4.2.2 AddressesCommon format in Guide E1239, PracticeE1715, and Practice E1744.4.2.3 Telephone NumbersGuide E1239 currently uses thesame representation with area code enclosed in parentheses andcountry code preceding the parentheses.4.2.4 DatesDate and time represented as ANS X3.51-1986/ISO

21、8601-1988 with years in four digits; time notseparated from date by “T” as permitted by ISO 8601.4.2.5 NumbersNumbers are represented either as integersor fixed point numbers; exponential notation not presentlyaccepted in Guide E1239 or HL-7. Units of Measure by ISO2955-1983 or ANS X3.50-86.4.2.6 St

22、rings7-bit ASCII characters; multilingual charac-ter sets not yet defined.55. Assignment of Coded Values5.1 The major important data elements in Guide E1384having coded data types and the current status of the catalogingof their values are:01035 Patient Multiple Birth code (5.2.23)01040 Sex (5.2.20)

23、01042 Biogeographic Ancestry (Race) (5.2.3)01045 Ethnicity (5.2.4)01047 Religion (5.2.7)01052 Marital status (5.2.2)01055 Nationality/Country of Origin (5.2.6)01057 Language (5.2.5)01060 Educational Level (5.2.8)Educational Certification (5.2.9)01062 Current Work Status (5.2.24)01065 Occupation (5.2

24、.11) also 01070,01090.0301067 Current Vocational Status (5.2.25)01085 Usual Living arrangement (5.2.26)01099 Foreign Residency Code (5.2.27)01090.03 Family Relationship (5.2.10)01155 Color Eyes (5.2.38)01160 Color Hair (5.2.39)01175 Body Build for Identification (5.2.40)02052 Durable Power of Attorn

25、ey Status (5.2.28)06001.01.15 Immunization reaction/result (5.2.63)04001.50 Professional Specialty (5.2.16)08005 Birth method (5.2.64)08095 Health History Response (5.2.76)09001.12 Body System/Region (5.2.22)09001.13 Exam Finding (5.2.77)09001.30 Tooth ID (5.2.74)09001.30.05 Tooth Surface (5.2.75)09

26、001.30.06 Tooth Sensitivity Code (5.2.65)09001.30.07 Tooth Mobility Code (5.2.66)09001.40.1 Prosthesis Type (5.2.67)11001.01.24 Test Specimen Source (5.2.68)14001.A002 Patient (Encounter) Type/Admission Source (5.2.17)14001.A004 Confidentiality Status (5.2.1)14001.A010 Encounter Status (5.2.69)14001

27、.A013 Facility Care/Healthcare setting (5.2.18)14001.A016 Reason for Visit (5.2.19)14001.A020 Encounter patient Arrival Condition (5.2.70)14001.A021 Mode of Arrival (5.2.29)14001.A030 Nature of Injury (5.2.30)14001.A033 Mode of Injury (5.2.31)14001.A034 Product of Injury (5.2.37)14001.A040 Injury On

28、 the Job Status (5.2.71)14001.A044 Protective Equipment Used (5.2.32)14001.A063 Patient Admission Type (5.2.12)14001.A110 Professional Specialty (5.2.16)14001.A133 Accommodation type (5.2.15)14001.A163.01 Patient In-residence Transfer Type (5.2.13)14001.A170 Diagnosis (5.2.33)14001.A170.01 Diagnosis

29、 Type (5.2.34)14001.A170.02 Diagnosis Status Code (5.2.35)14001.A186.01 Current Clinical Status (5.2.36)14001.A206 Police Hold Status (5.2.72)14001.A213 Medical Examiner Notification Code (5.2.73)14001.A223 Source of Payment Code (5.2.21)14001.F050 Discharge Disposition Category (5.2.14)This standar

30、d identifies the current value list for each ofthese elements as of the approval date of this standard (seefootnote 1) and states the evolving status of this catalog as theknowledge of the use of these elements expands as a result ofongoing investigation. Each element is identified by the indexassig

31、ned to it in the revised Appendix X1 of Guide E1384.Moreover, the definition for that element from the DataElement Catalog (1) is included with the value set.5.2 Value Set TablesThese tables collect the representationof coded data values for specific data elements in computer-based patient record st

32、ructures identified in Appendix X1 ofGuide E1384. The terms listed here are the minimal essentialones but may be further subclassified to include more specificterms by appropriate extensions of the included terms.5.2.1 Confidentiality StatusThis data element, Index:14001.A004, contains the minimal c

33、ommonly used valuesappearing in both manual and automated systems.Unwed mother UWMCelebrity VIPPsychiatric patient PSYEmployee EMPAIDS patient AIDHIV patient HIVAlcohol/Drug patient ETHUsual control URestricted RVery restricted V5.2.2 Marital StatusThis data element, Index: 01052,encompasses the val

34、ues noted by Westermeyer (2), Bureau ofCensus, the VA DHCP system, the DoD CHCS system, theX12 835 Transaction Set (3) , UB-82 (4), and used in commonpractice.Never married BSingle SMarried MDivorced DDivorced/annulled LDivorced/separated HAnnulled N5The boldface numbers in parentheses refer to the

35、list of references at the end ofthis standard.E1633 08a (2013)12Widowed WSeparated, NOS ASeparated, legal ESeparated, nonlegal KMarriage, separation, temporary absence XMarriage, separation, permanent absence VConsensual union JUnknown UCommon Law CDomestic Partner PRegistered Domestic Partner RLivi

36、ng together GInterlocutory IOther OUnreported T5.2.3 Biogeographic Ancestry (previously stated as:Race)This data element, Index: 01042, indicates the re-gion of the world from which the patients ancestors came.This is a biologic attribute that very generally indicatespossible biologic diversity to w

37、hich the patient might besubject. Due to ambiguity inherent in the diversity of the largenumber of inherited attributes which might characterize suchancestry, other data elements of the care record will be requiredto assign full meaning to the value set recorded for thisattribute. The name originate

38、s from recommendations in thegenetics literature (Am J Hum Gent 77:519-532 2005).Therefore, utilization of these other attributes is stronglyrecommended. To be consistent with census data, the six valuescurrently given in OMB Directive 15 are shown for relation-ship to the recommended new terms. New

39、 subcategories maybe added as recommended by the genetics professional disci-plines. The check digit for the code is calculated via programshown in Appendix X1. Note that NOS in the term means “NotOtherwise Specified.”Proposed Term Code Present TermAFRICA:NOS 2054-5 BLACKAFRICA:WEST AFRICA 0218-AFRI

40、CA:CENTRALSUB-SAHARAN AFRICA0219-AFRICA:EAST AFRICA 0220-AFRICA:SOUTHERN AFRICA 0221-AMERICA:NOS 1002-5 AMERICAN INDIAN/ALASKA NATIVEAMERICA:NORTH AMERICA(ABORIGINAL)0222-AMERICA:CENTRAL AMERICA/CARIBBEAN (ABORIGINAL)0223-AMERICA:SOUTH AMERICA 0224-EAST ASIA:NOS 2028-9 ASIANEAST ASIA:CENTRAL ASIA 02

41、25-EAST ASIA:NORTHERN ASIA 0226-EAST ASIA:EAST ASIA 0227-EAST ASIA:SOUTH ASIA 0228-EAST ASIA:SOUTHEAST ASIA 0229-EAST ASIA:AUSTRALIA (ABORIGINAL) 0230-EURASIA:NOS 2106-3 WHITEEURASIA:WESTERN EUROPE 0231-EURASIA:NORTHERN EUROPE 0232-EURASIA:EASTERN EUROPE 0233-EURASIA:SOUTHERN EUROPE/MEDITERANIAN0234

42、-EURASIA:NORTH AFRICA 0235-EURASIA:NEAR EAST 0236-EURASIA:ARABIAN PENINSULA 0237-EURASIA:WESTERN EURASIA 0238-OCEANIA:NOS 2076-8 HAWAIIAN/PACIFIC ISLANDEROCEANIA:PACIFIC ISLANDS 0239-OTHER 2131-35.2.4 EthnicityIn keeping with current demographicpractice, this data element, Index: 01045, reflects the

43、 ethniccultural group with which the patient identifies. Multipleselections may be made. Each value has associated with it anancestral cultural origin tag that is most closely associated withthe ancestral geographic origin of that cultural pattern. This tagdoes not signify the ancestral biologic cha

44、racteristics of theindividual which is recorded in other data elements of therecord. See Table 1.E1633 08a (2013)13TABLE 1 Ethnic GroupCDC Unique ID Name1070-2 AMER IND/ALASKA NAT:CENTRAL AMER IND,NOS2162-6 AMER IND/ALASKA NAT:CENTRAL AMERICAN IND,HISPANIC,NOS0128- AMER IND/ALASKA NAT:HISPANIC,CUBAN

45、2153-5 AMER IND/ALASKA NAT:HISPANIC,MEXICAN0131- AMER IND/ALASKA NAT:HISPANIC:PUERTO RICAN0130- AMER IND/ALASKA NAT:LATIN AMERICAN,HISP DESCENT,NOS0129- AMER IND/ALASKA NAT:LATIN AMERICAN,OTHER DESCENT1002-5 AMER IND/ALASKA NAT:NOS1073-6 AMER IND/ALASKA NAT:SOUTH AMERICAN IND,NOS2175-8 AMER IND/ALAS

46、KA NAT:SOUTH AMERICAN IND,HISPANIC,NOS1986-9 AMER IND/ALASKA NAT:US CAN IND,ALEUT,CHUGACH CORPORATION1966-1 AMER IND/ALASKA NAT:US/CAN IND,ALEUT,NOS1840-8 AMER IND/ALASKA NAT:US/CAN IND,INUIT,NOS1004-1 AMER IND/ALASKA NAT:US/CAN IND,NOS0132- AMER IND/ALASKA NAT:US/CAN IND,ALABAMA0133- AMER IND/ALASK

47、A NAT:US/CAN IND,COUSHATTA1010-8 AMER IND/ALASKA NAT:US/CAN IND,APACHE1026-4 AMER IND/ALASKA NAT:US/CAN IND,ARIKARA1021-5 AMER IND/ALASKA NAT:US/CAN IND,ARAPAHOE,NOS1028-0 AMER IND/ALASKA NAT:US/CAN IND,ASSINIBOINE1033-0 AMER IND/ALASKA NAT:US/CAN IND,BANNOCK1035-5 AMER IND/ALASKA NAT:US/CAN IND,BLA

48、CKFOOT1044-7 AMER IND/ALASKA NAT:US/CAN IND,CAHUILLA0125- AMER IND/ALASKA NAT:US/CAN IND,COPALIS1078-5 AMER IND/ALASKA NAT:US/CAN IND,CAYUSE1393-8 AMER IND/ALASKA NAT:US/CAN IND,CELILO1088-4 AMER IND/ALASKA NAT:US/CAN IND,CHEROKEE,NOS1102-3 AMER IND/ALASKA NAT:US/CAN IND,CHEYENNE,NOS1112-2 AMER IND/

49、ALASKA NAT:US/CAN IND,CHICKASAW1816-8 AMER IND/ALASKA NAT:US/CAN IND,CHILKAT1114-8 AMER IND/ALASKA NAT:US/CAN IND,CHINOOK,NOS1123-9 AMER IND/ALASKA NAT:US/CAN IND,CHIPPEWA,NOS1191-6 AMER IND/ALASKA NAT:US/CAN IND,CREE,NOS1155-1 AMER IND/ALASKA NAT:US/CAN IND,CHOCTAW1153-6 AMER IND/ALASKA NAT:US/CAN IND,CHITIMACHA1725-1 AMER IND/ALASKA NAT:US/CAN IND,YUMAN,COCOPAH1167-6 AMER IND/ALASKA NAT:US/CAN IND,COEUR DALENE0134- AMER IND/ALASKA NAT:US/CAN IND,COMANCHE1080-1 AMER IND/ALASKA NAT:US/CAN IND,CHEHALIS1173-4 AMER IND/ALASKA NAT:US/CAN IND,COLV