1、Designation: E1239 04 (Reapproved 2010) An American National StandardStandard Practice forDescription of Reservation/Registration-Admission,Discharge, Transfer (R-ADT) Systems for Electronic HealthRecord (EHR) Systems1This standard is issued under the fixed designation E1239; the number immediately
2、following the designation indicates the year oforiginal adoption or, in 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.1. Scope1.1 This practic
3、e identifies the minimum information capa-bilities needed by an ambulatory care system or a residentfacility R-ADT system. This practice is intended to depict theprocesses of: patient registration, inpatient admission intohealth care institutions and the use of registration data inestablishing and u
4、sing the demographic segments of theelectronic health record. It also identifies a common core ofinformational elements needed in this R-ADT process andoutlines those organizational elements that may use thesesegments. Furthermore, this guide identifies the minimumgeneral requirements for R-ADT and
5、helps identify many ofthe additional specific requirements for such systems. The dataelements described may not all be needed but, if used, theymust be used in the way specified so that each record segmenthas comparable data. This practice will help answer questionsfaced by designers of R-ADT capabi
6、lities by providing a cleardescription of the consensus of health care professionalsregarding a uniform set of minimum data elements used byR-ADT functions in each component of the larger system. Itwill also help educate health care professionals in the generalprinciples of patient care information
7、management as well asthe details of the constituent specialty areas.1.2 This standard does not purport to address all of thesafety concerns, if any, associated with its use. It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the a
8、pplica-bility of regulatory requirements prior to use.2. Referenced Documents2.1 ASTM Standards:2E1384 Practice for Content and Structure of the ElectronicHealth Record (EHR)E1633 Specification for CodedValues Used in the ElectronicHealth RecordE1714 Guide for Properties of a Universal Healthcare Id
9、en-tifier (UHID)E1715 Practice for An Object-Oriented Model forRegistration, Admitting, Discharge, and Transfer (RADT)Functions in Computer-Based Patient Record SystemsE1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health Re
10、cords2.2 ANSI Standards:3ANS X3.38 Identification of States of the United States forInformation InterchangeANS X3.47 Structure of the Identification of Name Popu-lated Places and Related Entities of the States of theUnited StatesNCCLS LIS-5A Specification for Transferring Clinical Ob-servations Betw
11、een Independent Computer SystemsNCCLS LIS-8A Guide for Functional Requirements ofClinical Laboratory Information Management SystemsNCCLS LIS-9A Guide for Coordination of Clinical Labora-tory Services within the Electronic Health Record Envi-ronment and Networked Architectures2.3 ISO Standards:4ISO 6
12、39 Names of LanguagesISO 3166 Names of CountriesISO 5218 Representation of Human Sexes1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.25 on HealthcareData Management, Security, Confidentiality, and Privacy.
13、This guide was preparedin collaboration with the American Health Information Management Assn.Current edition approved March 1, 2010. Published August 2010. Originallyapproved in 1988. Last previous edition approved in 2004 as E123904. DOI:10.1520/E1239-04R10.2For referenced ASTM standards, visit the
14、 ASTM website, www.astm.org, orcontact ASTM 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 1
15、0036, http:/www.ansi.org.4Available from International Organization for Standardization (ISO), 1, ch. dela Voie-Creuse, Case postale 56, CH-1211, Geneva 20, Switzerland, http:/www.iso.ch.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
16、NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.Contact ASTM International (www.astm.org) for the latest information12.4 Federal Information Processing Standard Publication:5FIPSPUB 6-2 Counties of the States of the United StatesFIPSPUB 5-1 States of the U
17、nited States3. Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 admissionformal acceptance by a hospital of apatient who is to be provided with room, board, and continuousnursing services in an area of the hospital where patientsgenerally stay overnight.3.1.2 basic data set for am
18、bulatory caredata items whichconstitute the minimum basic set of data that should be enteredin the record concerning all ambulatory medical care encoun-ters.3.1.3 clinic outpatientadmitted to a clinical service of ahospital for diagnosis or therapy on an ambulatory basis in aformally organized unit
19、of a medical or surgical specialty orsubspecialty. The clinic assumes overall medical responsibilityfor the patient.3.1.4 dischargetermination of a period of inpatient hospi-talization through the formal release of the inpatient by thehospital.3.1.5 dispositiondirecting of a patient from oneenvironm
20、ent/health care delivery mode to another at conclu-sion of services.3.1.6 emergency patientadmitted to emergency room ser-vice of a hospital for diagnosis and therapy of a condition thatrequires immediate medical, dental, or allied services.3.1.7 encounterface-to-face contact between a patient anda
21、provider who has primary responsibility for assessing andtreating the patient at a given contact, exercising independentjudgment.3.1.8 inpatientan individual receiving, in person, residenthospital-based or coordinated medical services for which thehospital is responsible.3.1.9 inpatient episodeperio
22、d of time in which the patientis in an inpatient status, beginning with admission and termi-nating with discharge.3.1.10 master patient indexpermanent listing that revealsidentity and location of patients treated by a health care facility.3.1.11 outpatientan individual receiving, in person, non-resi
23、dent, provider-supplied or coordinated medical services forwhich the provider is responsible. The types of outpatientsrecognized are:3.1.11.1 Emergency3.1.11.2 Clinic, and3.1.11.3 Referred.3.1.12 patient care recordlegal documented record ofhealth care services provided by a health care facility. Sy
24、nony-mous with: medical record, health record, patient record.3.1.13 practitioner specialtyfor a particular practitioner,the subject area of health care or scope of health care servicesin which the major share of his or her practice is carried out.See National Provider System Taxonomy in Specificati
25、onE1633.3.1.14 registrationrecording the patient demographic andfinancial data in a unit record for patient care or a billing recordfor charge capture, respectively.3.1.15 referred outpatientadmitted exclusively to a spe-cial diagnostic/therapeutic service of the hospital for diagnosis/treatment on
26、an ambulatory basis. Responsibility remains withthe referring physician.3.1.16 specialty typeclassification of specialized fields ofmedical services, such as, for example, Gynecology, GeneralSurgery, Orthopedic Surgery, etc.3.1.17 transferchange in medical care unit, medical staff,or responsible phy
27、sician of an inpatient during hospitalization.3.1.18 uniform hospital discharge data setThose essentialdata elements which should be recorded to provide a compositepicture of the patients stay.3.2 Acronyms:CPR Computer-based Patient RecordEHR Electronic Health RecordR-ADT Registration-Admission, Dis
28、charge, TransferADT Admittng, Discharge, TransferR-RADT Registration/Reservation-Admitting, Discharge,TransferMPI Master Patient/Person Index4. Significance and Use4.1 Background:4.1.1 Effective health care delivery requires an efficientinformation base. A standard description is needed regardingthe
29、 capabilities of Registration-Admission, Discharge, Transfer(R-ADT) Systems in both automated hospital and ambulatorycare information systems. This practice is intended not only toprovide a common explanation of the minimum informationelements required in such systems, thus augmenting thosealready p
30、ublished6,7but also to provide the basis for futurepatient data interchange formats. This practice has been devel-oped to serve as a uniform minimum description of R-ADTfunctional components that should be common in all systemsand used in both transportable general purpose and customdeveloped system
31、s. This description requires acceptance of thepremise regarding the need for logical integration of conceptsin systems development. In the integrated systems concept, theR-ADT function is the foundation module for all patientinformation and communication among all departments, and itis used in initi
32、ating services within the patient care setting. Acommon R-ADT system in a hospital enables all departmentsto streamline the initiation and tracking of the services theyprovide to patients; it also provides an opportunity for accuratetracking of patient movement throughout a hospital stay, forinstanc
33、e, and the linkage of inpatient and outpatient services. Itis also the system which provides all inpatient census-relatedadministrative reports. Likewise, an R-ADT component in an5Available from US Dept. of Commerce, Government Printing Office,Washington, DC.6Uniform Ambulatory Medical Care: Minimum
34、 Data Set, DHHS PublicationPHS 81-1161, DHHS National Center for Health Statistics, 1981.7Uniform Hospital Discharge Data Set, DHHS Publication HSM 74-1451,Health Information Policy Council DHHS, 1984.E1239 04 (2010)2EnterpriseArchitecture captures the initial patient demographicprofile for the EHR
35、and is subsequently accessed in posting anindividuals clinical data, for inquiry regarding that clinicaldata and for linkage to financial records. It is an integral part ofthe EHR function. It may also be linked to other systems whichprovide patient care information management capabilities.4.1.2 A r
36、egistration system is capable of providing theinitial information capture for all health care facilities; anADTsubsystem can provide common admitting data for all depart-ments in hospitals and other inpatient facilities. Establishing astandard description of a logical R-ADT process model isuseful be
37、cause that standard will become a reference for otherdocuments describing the other functional subsystems used inpatient care information systems. It is understood that aminimum set of information elements must be initially cap-tured upon registration and then used for all subsequentambulatory or in
38、patient care; the subsequent minimum set ofadmitting elements is then used to drive or initiate additionalservices for patients through each subsystem. With a standardminimum R-ADT component definition, standards for con-stituent subsystems can now be coordinated and developedthrough reference to th
39、is model. This description should beused by vendors and subsystem designers who need to developtheir systems in a coordinated and integrated way so that eachsubsystem will contribute modularly with overall systemsplanning for the user organization. Such modularity will aidmanagement who are assigned
40、 to evaluate each system andsubsystem in order to assess the potential of existing technol-ogy to provide the needed patient care information manage-ment systems capabilities.4.2 UseThis practice is written assuming that the healthcare facility will have several options for gaining the R-ADTcapabili
41、ty and may either acquire a system from a commercialvendor or design an integrated in-house system which may bea component of an ambulatory care practice or a hospitalinformation system. Many of the characteristics of existingvendor systems are conventional and can interoperate; the carefacility may
42、 simply need to identify whether or not the offeredfeatures meet its needs. Beyond the general capabilities, theunique systems capabilities can then be identified and struc-tured to meet the special needs of that individual enterprise. Amore accurate selection can therefore be made from thefeatures
43、offered by vendors if each health care facility/hospitalcarefully identifies its own R-ADT functional requirementswith the aid of this guide prior to evaluating candidate systemsor development approaches and specifying that these require-ments be met.4.3 Role of R-ADT Systems in Integrated DeliveryS
44、ystemsRegistration/Reservation-Admission, Discharge.Transfer functions in integrated delivery systems need toprovide a uniform enterprise view with data accessible acrossthe IDS. Typical functions in this environment may includeregistration to an enterprise master patient index, reportingcapabilitie
45、s on R-ADT functions, enterprise scheduling andenterprise capabilities for eligibility and utilization manage-ment. Patient data collected should be transferable to medicalrecord abstract applications and contribute to clinical reposi-tories to maintain longitudinal focus to evolve toward elec-troni
46、c health records. IDS networks provide infrastructure andshould conform to enterprise technical security requirementsthat meet legal and accreditation requirements.5. System Description5.1 General Principles and PurposeThe purposes of anR-ADT system are to:5.1.1 Identify or verify patients, or both,
47、 via a facility masterpatient index created and maintained through the registrationprocess.5.1.2 Establish an initial record of the patient entry into thesystem by creating the demographic segment of the EHR(registration).5.1.3 Maintain the registration record and demographic dataas a common node fo
48、r patient care record systems so that it canbe used by all ancillary support systems.5.1.4 Augment the registration record by addition of thosedata required for any inpatient admission.5.1.5 Initiate services for all inpatients admitted to thefacility by providing notification of the start of servic
49、es.5.1.6 Track movements of the inpatient throughout hospi-talization.5.1.7 Facilitate scheduling of ancillary and clinical servicesthrough a bed control and transfer function.5.1.8 Produce the inpatient census data and the correspond-ing census and statistical reports.5.1.9 Identify movement, location, status, and discharge ofeach in-patient and the times and dates of these events, thishelps coordinate efficient support services for treating thatpatient during hospitalization. This is achieved by means ofcensus reporting and afterwards during foll
