ASTM E1633-2008a Standard Specification for Coded Values Used in the Electronic Health Record《编码值标准规范的电子健康记录中使用》.pdf

1、Designation: E 1633 08aAn American National StandardStandard Specification forCoded Values Used in the Electronic Health Record1This standard is issued under the fixed designation E 1633; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revis

2、ion, 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.1. Scope*1.1 This specification covers the identification of the lexi-cons to be used for the data elements ident

3、ified inAppendix X1of Guide E 1384. 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 other healthcare data message exchangeformat standards, or (4) in data gathe

4、ring 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 specification is applicable to all paper andautomated systems.2. Referenced Do

5、cuments2.1 ASTM Standards:2E 1238 Specification for Transferring Clinical ObservationsBetween Independent Computer Systems3E 1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT)Systems for Electronic Health Record (EHR) SystemsE 1384 Practice for Content a

6、nd Structure of the ElectronicHealth Record (EHR)E 1715 Practice for An Object-Oriented Model for Regis-tration, Admitting, Discharge, and Transfer (RADT) Func-tions in Computer-Based Patient Record SystemsE 1744 Practice for View of Emergency Medical Care in theElectronic Health Record2.2 ANSI Stan

7、dards:4ANS X3.50 Representation of Date and TimeANS X3.51 Representation of Common Units2.3 ISO Standards:4ISO 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 Indust

8、ry Level 7 Interface Standards53. Terminology3.1 Acronyms: 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 E 1384, concernedwith the structure a

9、nd content of the computer-based patientrecord, 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 E 1384

10、 now provides a means of cataloging the valuesets representing each data element (see Guide E 1384).Specification E 1238, coordinated with Guide E 1239, de-scribes conventions for representing many of the data valuesfor data elements that are included in the more comprehensivelisting in Guide E 1384

11、. A comprehensive listing of all of thevalue sets associated with Guide E 1384 has 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 tradi

12、tionally assigned representations foreach of these elements, and it must resolve differences 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, whil

13、e at the same time maximizing familiar1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data Management, Security, Confidentiality, and Privacy.Current edition approved July 15, 2008. Publ

14、ished August 2008. Originallyapproved in 1996. Last previous edition approved in 2008 as E 163308.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Docu

15、ment Summary page onthe ASTM website.3Withdrawn.4Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.5Available from Health Level 7, Mark McDougall, Executive Director, 900Victors Way, Suite 122, Ann Arbor, MI 48108.1*A Summar

16、y 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.or traditional representations. This standard has been devel-oped with input from many organizations, including govern-ment agenc

17、ies and other standards bodies and professionalassociations, and as a result of the effort to achieve consistencyand comprehensiveness among the data dealt with by variousstandards efforts.4.2 General ValuesEarly in the coordination of healthcareinformation standards an informal body, the Healthcare

18、 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 stage for the development of the value setsfor the CODED VALUE data type. The status of the sta

19、ndardnoncoded data types, and their representations, agreed upon bythe HISCC are:4.2.1 Person NamesSpecification E 1238, Guide E 1239,Practice E 1715, Practice E 1744, and HL-7 use the samerepresentation for American and European forms.4.2.2 AddressesCommon format in Specification E 1238,Guide E 123

20、9, Practice E 1715, and Practice E 17444.2.3 Telephone NumbersSpecification E 1238 and GuideE 1239 currently use the same representation with area codeenclosed in parentheses and country code preceding the paren-theses.4.2.4 DatesDate and time represented as ANS X3.51-1986/ISO 8601-1988 with years i

21、n four digits; time not sepa-rated 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 Specification E 1238, Guide E 1239,orHL-7.Units of Measure by ISO 2955-1983 or ANS X3.50-86.4.2.6

22、Strings7-bit ASCII characters; multilingual charac-ter sets not yet defined.65. Assignment of Coded Values5.1 The major important data elements in Guide E 1384having 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.

23、20)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 (

24、5.2.11) 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 Att

25、orney 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

26、)09001.30.06 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)14

27、001.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

28、 On 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 Diagno

29、sis 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 stan

30、dard 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 indexas

31、signed to it in the revised Appendix X1 of Guide E 1384.Moreover, the definition for that element from the DataElement Catalog (5) is included with the value set.5.2 Value Set TablesThese tables collect the representa-tion of coded data values for specific data elements incomputer-based patient reco

32、rd structures identified in Appen-dix X1 of Guide E 1384. The terms listed here are the minimalessential ones but may be further subclassified to include morespecific terms by appropriate extensions of the included terms.5.2.1 Confidentiality StatusThis data element, Index:14001.A004, contains the m

33、inimal commonly used valuesappearing in both manual and automated systems. See Speci-fication E 1238.Unwed mother UWMCelebrity VIPPsychiatric patient PSYEmployee EMPAIDS patient AIDHIV patient HIVAlcohol/Drug patient ETHUsual control URestricted RVery restricted V5.2.2 Marital StatusThis data elemen

34、t, Index: 01052,encompasses the values noted by Westermeyer (6), Bureau ofCensus, the VA DHCP system, the DoD CHCS system, theX12 835 Transaction Set (7), UB-82 (8), and used in commonpractice.Never married B6The boldface numbers in parentheses refer to the list of references at the end ofthis stand

35、ard.E 1633 08a2Single SMarried MDivorced DDivorced/annulled LDivorced/separated HAnnulled NWidowed WSeparated, NOS ASeparated, legal ESeparated, nonlegal KMarriage, separation, temporary absence XMarriage, separation, permanent absence VConsensual union JUnknown UCommon Law CDomestic Partner PRegist

36、ered Domestic Partner RLiving together GInterlocutory IOther OUnreported T5.2.3 Biogeographic Ancestry (previously stated as:Race)This data element, Index: 01042, indicates theregion of the world from which the patients ancestors came.This is a biologic attribute that very generally indicatespossibl

37、e biologic diversity to which 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 thisattr

38、ibute. The name originates from recommendations in thegenetics literature (Am J Hum Gent 77:519-532 2005). There-fore, utilization of these other attributes is strongly recom-mended. To be consistent with census data, the six valuescurrently given in OMB Directive 15 are shown for relation-ship to t

39、he recommended new terms. New subcategories maybe added as recommended by the genetics professional disci-plines. The check digit for the code is calculated via programpreviously given in Specification E 1238 and shown in Appen-dix X1. Note that NOS in the term means “Not OtherwiseSpecified.”Propose

40、d Term Code Present TermAFRICA:NOS 2054-5 BLACKAFRICA:WEST AFRICA 0218-AFRICA:CENTRALSUB-SAHARAN AFRICA0219-AFRICA:EAST AFRICA 0220-AFRICA:SOUTHERN AFRICA 0221-AMERICA:NOS 1002-5 AMERICAN INDIAN/ALASKA NATIVEAMERICA:NORTH AMERICA (ABORIGI-NAL)0222-AMERICA:CENTRAL AMERICA/CARIBBEAN (ABORIGINAL)0223-A

41、MERICA:SOUTH AMERICA 0224-EAST ASIA:NOS 2028-9 ASIANEAST ASIA:CENTRAL ASIA 0225-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 EUR

42、OPE 0232-EURASIA:EASTERN EUROPE 0233-EURASIA:SOUTHERN EUROPE/MEDITERANIAN0234-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 wi

43、th current demographic prac-tice, this data element, Index: 01045, reflects the ethnic culturalgroup with which the patient identifies. Multiple selectionsmay be made. Each value has associated with it an ancestralcultural origin tag that is most closely associated with theE 1633 08a3ancestral geogr

44、aphic origin of that cultural pattern. This tagdoes not signify the ancestral biologic characteristics of theindividual which is recorded in other data elements of therecord. See Fig. 1.5.2.5 LanguageThis data element, Index 01058, is speci-fied by the two character lower case code in ISO 639 Table

45、1.The upper case three character code, now in ISO balloting maybe added in a future revision of this specification. The languagesymbol only is shown here, but an original name and Frenchlanguage name are available (see Fig. 2 for list).5.2.6 Nationality/Country of OriginThis data element,Index: 0105

46、5, Citizenship, is specified by ISO 3166. The twoletter codes are shown here. A three letter and a numeric codeexists for each entry. New entries may be added in the future.AFG AF AFGHANISTANALB AL ALBANIADZA DZ ALGERIAASM AS AMERICAN SAMOAAND AD ANDORRAAGO AO ANGOLAAI ANGUILLAATA AQ ANTARCTICAATG A

47、G ANTIGUA AND BURBUDAARG AR ARGENTINAARM ARMENIAABW AW ARUBAAUS AU AUSTRALIAAUT AT AUSTRIAAZE AZERBIAJANBHS BS BAHAMASBHR BH BAHRAINBGD BD BANGLADESHBRB BB BARBADOSBLR BELARUSBEL BE BELGIUMBLZ BY BELIZEBEN BJ BENINBMU BM BERMUDABTN BT BHUTANBOL BO BOLIVIABIH BOSNIA HERZOGOVINABWA BW BOTSWANABVT BV B

48、OUVET ISLANDBRA BR BRAZILIOT IO BRITISH INDIAN OCEAN TERRITORYBRN BN BRUNEI DARUSSALAMBGR BG BULGARIABFA BF BURKINA FASOMMR BU BURMA/MYANMARBDI BI BURUNDIKAM KH CAMBODIACMR CM CAMEROONCAN CA CANADACPV CV CAPE VERDEKY CAYMAN ISLANDSCAF CENTRAL AFRICAN REPUBLICTCD TD CHADCHL CL CHILECHN CN CHINACXR CX

49、 CHRISTMAS ISLANDCCK CC COCOS (KEELING) ISLANDSCOL CO COLUMBIAKM COMOROSCOG CG CONGO (FORMERLY ZAIRE)COD CONGO,DEMOCRATIC REPUBLIC OFCOK CK COOK ISLANDSCRI CR COSTA RICACIV CI COTE DIVORIEHRV CROATIACUB CU CUBACYP CY CYPRUSCZE CS CZECH REPUBLICDNK DK DENMARKDJI DJ DJIBOUTIDMA DM DOMINICADOM DO DOMINICAN REPUBLICTMP TP EAST TIMORECU EC ECUADOREGY EG EGYPTSLV SV EL SALVADORGNQ GQ EQUITORIAL GUINEAEST ESTONIAETH ET ETHIOPIAFLK FK FALKLAND ISLANDSFRO FO FAROE ISLANDSFJI FJ FIJIFIN FI FINLANDFRA FR FRANCEGUF GF FRENCH GUYANAPYF PF FRENCH POLYNESIAAFT TF FRENCH SOUT