1、Designation: E1384 07 (Reapproved 2013) An American National StandardStandard Practice forContent and Structure of the Electronic Health Record(EHR)1This standard is issued under the fixed designation E1384; the number immediately following the designation indicates the year oforiginal adoption or,
2、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. Scope*1.1 This practice covers all types of healthcare services,including those given in a
3、mbulatory care, hospitals, nursinghomes, skilled nursing facilities, home healthcare, and spe-cialty care environments. They apply both to short termcontacts (for example, emergency rooms and emergency medi-cal service units) and long term contacts (primary care physi-cians with long term patients).
4、 The vocabulary aims to encom-pass the continuum of care through all delivery models. Thispractice defines the persistent data needed to support ElectronicHealth Record system functionality.1.2 This practice has four purposes:1.2.1 Identify the content and logical data structure andorganization of a
5、n Electronic Health Record (EHR) consistentwith currently acknowledged patient record content. The re-cord carries all health related information about a person overtime. It may include history and physical, laboratory tests,diagnostic reports, orders and treatments documentation, pa-tient identifyi
6、ng information, legal permissions, and so on. Thecontent is presented and described as data elements or asclinical documents. This standard is consistent with eXtensibleMarkup Language (XML). See Document Type Definition(DTD) 2.1 and W3CXML Schema 1.01.2.2 Explain the relationship of data coming fro
7、m diversesources (for example, clinical laboratory information manage-ment systems, order entry systems, pharmacy informationmanagement systems, dictation systems), and other data in theElectronic Health Record as the primary repository for infor-mation from various sources.1.2.3 Provide a common vo
8、cabulary for those developing,purchasing, and implementing EHR systems.1.2.4 Provide sufficient content from which data extractscan be compiled to create unique setting “views.”1.2.5 Map the content to selected relevant biomedical andhealth informatics standards.2. Referenced Documents2.1 ASTM Stand
9、ards:2E1238 Specification for Transferring Clinical ObservationsBetween Independent Computer Systems (Withdrawn2002)3E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) SystemsE1633 Specification for Coded Values
10、 Used in the ElectronicHealth RecordE1639 Guide for Functional Requirements of Clinical Labo-ratory Information Management Systems (Withdrawn2002)3E1714 Guide for Properties of a Universal Healthcare Iden-tifier (UHID)E1715 Practice for An Object-Oriented Model forRegistration, Admitting, Discharge,
11、 and Transfer (RADT)Functions in Computer-Based Patient Record SystemsE1769 Guide for Properties of Electronic Health Recordsand Record SystemsE2118 Guide for Coordination of Clinical Laboratory Ser-vices within the Electronic Health Record Environmentand Networked Architectures (Withdrawn 2002)3E23
12、69 Specification for Continuity of Care Record (CCR)E2473 Practice for the Occupational/Environmental HealthView of the Electronic Health RecordE2538 Practice for Defining and Implementing Pharmaco-therapy Information Services within the Electronic HealthRecord (EHR) Environment and Networked Archit
13、ecturesHL72.2 Other Health Informatics Standards:HL7 Health Level Seven (HL7) Version 2.2 19944(Version2.4 and 2.5)NCPDP National Council for Prescription Drug Programs1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommi
14、ttee E31.25 on HealthcareData Management, Security, Confidentiality, and Privacy.Current edition approved April 15, 2013. Published April 2013. Originallyapproved in 1991. Last previous edition approved in 2007 as E1384 07. DOI:10.1520/E1384-07R13.2For referenced ASTM standards, visit the ASTM websi
15、te, 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.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from HL7, Mark McD
16、ougall, Executive Director, 900 Victors 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 has either been supersede
17、d and replaced by a new version or withdrawn.Contact ASTM International (www.astm.org) for the latest information1(NCPDP) Telecommunication Standard Format Version3 Release 2, 19925ANSI ASC X12: Version 3, Release 3 (1992)6X12.84 Healthcare Enrollment and Maintenance TransactionSet (834)7X12.85 Heal
18、thcare Claim Payment Transaction Set (835)7X12.87 Healthcare Claim Transaction Set (837)72.3 ANSI Standards:7HL7 EHR TC Electronic Health Record-System FunctionalModel, Release 1 February, 2007Health Information Management and Technology: Glossary,American Health Information Management Association,2
19、0063. Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 admitting diagnosisa provisional description of thereason why a patient requires care in an inpatient hospitalsetting.3.1.2 ambulatory carepreventive or corrective healthcareservices provided on a nonresident basis in a provid
20、ers office,clinic setting, or hospital outpatient setting. The term ambula-tory usually implies that the patient has come to a location andhas departed that same day. (Ambulatory care includes medi-cine such as acupuncture, specialty clinics for consultationservices and retail care centers used for
21、short term immediateservices.)3.1.3 ancillary service visitappearance of an outpatient ina unit of a hospital or outpatient facility to receive service(s),test(s), or procedures; it is ordinarily not counted as anencounter for healthcare services.3.1.4 clinican outpatient facility providing a limite
22、d rangeof healthcare services, and assuming overall healthcare respon-sibility for the patients. See also ambulatory care.3.1.5 clinic patienta patient who is registered for thepurpose of diagnosis or treatment or follow-up on an ambula-tory basis.3.1.6 continuing care retirement communityan organiz
23、a-tion established to provide housing and services, includinghealthcare, to people of retirement age.3.1.7 electronic health record (EHR)an electronic healthrecord is any information related to the past, present or futurephysical/mental health, or condition of an individual. Theinformation resides i
24、n electronic system(s) used to capture,transmit, receive, store, retrieve, link and manipulate multime-dia data for the primary purpose of providing health care andhealth related services.3.1.8 emergency patienta patient admitted to emergencyroom service of a hospital for diagnosis and therapy requi
25、ringimmediate healthcare services.3.1.9 emergency servicesimmediate evaluation andtherapy rendered in urgent clinical conditions, sustained untilthe patient can be referred to his or her personal practitioner forfurther care.3.1.10 encounter(1) the direct personal contact between apatient and a phys
26、ician or other person who is authorized bystate licensure law and, if applicable, by medical staff bylawsto order or furnish healthcare services for the diagnosis ortreatment of the patient. (2) A contact between a patient and apractitioner who has primary responsibility for assessing andtreating th
27、e patient at a given contact, exercising independentjudgment. Contact may be via an electronic visit.3.1.11 episodeone or more healthcare services receivedby an individual during a period of relatively continuous careby healthcare practitioners in relation to a particular clinicalproblem or situatio
28、n.3.1.11.1 episode of care (EOC reimbursement)a categoryof payments made as lump sums to providers for all healthcareservices delivered to a patient for a specific illness or over aspecified time period or both; also called bundled paymentsbecause they include multiple services and may include mul-t
29、iple providers of care.3.1.12 free standing ambulatory surgery centera) A freestanding outpatient surgical facility is a separate facility thatexists primarily to provide services in connection with surgicalprocedures that do not require inpatient hospitalization. b) Anoutpatient surgical facility t
30、hat has its own national identifier;is a separate entity with respect to its licensure, accreditation,governance, professional supervision, administrative functions,clinical services, record keeping, and financial and accountingsystems; has as its sole purpose the provision of services inconnection
31、with surgical procedures that do not require inpa-tient hospitalization; and meets the conditions and require-ments set forth in the Medicare Conditions of Participation.3.1.13 health maintenance organizationan organizationthat provides health coverage to voluntary enrollees in returnfor prepayment
32、of a set fee, regardless of the services used.3.1.14 home healtha) An umbrella term that refers to themedical and non-medical services provided to patients andtheir families in their places of residence. b) The provision ofmedical and non-medical care in the home or place ofresidence to promote, mai
33、ntain, or restore health or to mini-mize the effect of disease or disability.3.1.15 hospicean interdisciplinary program of palliativecare and supportive services that addresses the physical,spiritual, social and economic needs of terminally ill patientsand their families.3.1.16 hospitalan establishm
34、ent with an organized medi-cal staff with permanent facilities that include inpatient bedsand continuous medical/nursing services and that providesdiagnostic and therapeutic services for patients as well asovernight accommodations and nutritional services.3.1.17 hospital-based outpatient carea subse
35、t of ambula-tory care utilizing the hospital staff, equipment, and resourcesto render diagnostic, preventive or corrective healthcare, orboth.5Available from NCPDP, 4201 North 24th Street, Suite 365, Phoenix,AZ 85016.6Available from DISA (Data Interchange Standards Association).7Available from Ameri
36、can National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036.E1384 07 (2013)23.1.18 inpatient admissionthe formal acceptance by ahospital of a patient who is to be provided with room, board,and continuous nursing service in an area of the hospital wherepatients generally sta
37、y overnight.3.1.19 intermediate care facility (ICF)an institutionwhich primarily provides health-related care and services toindividuals who do not require the degree of care or treatmentwhich a hospital or skilled nursing facility is designated toprovide, but who, because of their physical or menta
38、lcondition, require care and services.3.1.20 length of stay (LOS)the total number of patientdays for an inpatient episode, calculated by subtracting the dateof admission from the date of discharge. If a patient is admittedand discharged on the same date, the LOS is one day.3.1.21 licensed practition
39、ersan individual at any level ofprofessional specialization who requires a public license/certification to practice the delivery of care to patients. Apractitioner can also be a provider.3.1.22 longitudinal patient recorda permanent, coordi-nated patient record of significant information, in chronol
40、ogi-cal sequence. It may include all historical data collected or beretrieved as a user designated synopsis of significantdemographic, genetic, clinical and environmental facts andevents maintained within an automated system.3.1.23 long-term carehealthcare rendered in a non-acute-care facility and t
41、o a patient in resident or nonresident status tochronically ill, aged, disabled or mentally handicapped indi-viduals who are in need of continual supervision and assistanceby healthcare practitioners.3.1.24 non-licensed practitioneran individual without apublic license/certification who is supervise
42、d by a licensed/certified individual in delivering care to patients.3.1.25 outpatient caresee ambulatory care.3.1.26 observationany aspect or attribute of a patient thatcan be described at a particular time. Examples include serumglucose finding, a chest x-ray impression, a bone density scanresult,
43、vital signs and a progress note.3.1.27 partial hospital programfacilities of the hospitalare regularly used on a scheduled basis for care during asubstantial number of daytime or nighttime hours.3.1.28 patient health recordthe primary legal record docu-menting the healthcare services provided to a p
44、erson, in anyaspect of healthcare delivery. This term is synonymous with:medical record, health record, patient care record (primarypatient record), client record, resident record. The term in-cludes routine clinical or office records, records of care in anyhealth-related setting, preventive care, l
45、ife style evaluation,research protocols, special study records and various clinicaldatabases.3.1.28.1 DiscussionAs the repository of informationabout a single patient, this information is generated by health-care professionals as a direct result of interaction with a patientor with individuals who h
46、ave personal knowledge of the patient(or with both). The record contains information about thepatient and other individuals as they relate to the health of thepatient, for example, family history, caregiver support.3.1.28.1 Personal health recordAn electronic or paperrecord of health information com
47、piled and maintained by thepatient or others for patient use (1) .3.1.29 patient record systemthe set of components thatform the mechanism by which patient records are created,used, stored, and retrieved. A patient record system is usuallylocated within a healthcare provider/practitioner setting. It
48、includes people, data, rules and procedures, processing andstorage devices (for example, paper and pen, hardware andsoftware), and communications and support functions.3.1.30 primary diagnosisthe diagnosis of the conditionthat is primarily responsible for the patients symptoms andsigns and has the g
49、reatest impact on the patients health, or isthe most resource-intensive to treat.3.1.31 principal diagnosisa statement of the conditionestablished after study to be chiefly responsible for occasioningthe admission of the patient to the hospital for care.3.1.32 providera business entity which furnishes health-care to a consumer; it includes a professionally licensedpractitioner who is authorized to operate a healthcare deliveryfacility.3.1.33 referred (patient)registered exclusively for specialdiagnostic/therapeutic service of the hosp
