ASTM E1239

1.1 This practice identifies the minimum information capabilities needed by an ambulatory care system or a resident facility R-ADT system. This practice is intended to depict the processes of: patient registration, inpatient admission into health care institutions and the use of registration data in establishing and using the demographic segments of the electronic health record. It also identifies a common core of informational elements needed in this R-ADT process and outlines those organizational elements that may use these segments. Furthermore, this guide identifies the minimum general requirements for R-ADT and helps identify many of the additional specific requirements for such systems. The data elements described may not all be needed but, if used, they must be used in the way specified so that each record segment has comparable data. This practice will help answer questions faced by designers of R-ADT capabilities by providing a clear description of the consensus of health care professionals regarding a uniform set of minimum data elements used by R-ADT functions in each component of the larger system. It will also help educate health care professionals in the general principles of patient care information management as well as the details of the constituent specialty areas.

1.2 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory requirements prior to use.

2. Referenced Documents

E1384 Practice for Description of Content and Structure of Electronic Health Record Systems
E1633 Specification for Coded Values Used in Electronic Health Record Systems
E1714 Guide for Properties of a Universal Health Identifier
E1715 Practice for Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (R-ADT) Functions in Electronic Health Record Systems
E1744 Guide for a View of Emergency Medical Care in the Computerized Medical Record
E1869 Guide for Confidentiality, Privacy, Access, and Data Principles for Health Information Including Electronic Health Records
ANSX3.38 Identification of States of the United States for Information Interchange
ANSX3.47 Structure of the Identification of Name Populated Places and Related Entities of the States of the United States
FIPSPUB 5-1 States of the United States
FIPSPUB 6-2 Counties of the States of the United States
ISO 3166 Names of Countries
ISO 5218 Representation of Human Sexes
ISO 639 Names of Languages
NCCLSLIS-5A Specification for Transferring Clinical Observations Between Independent Computer Systems
NCCLSLIS-8A Guide for Functional Requirements of Clinical Laboratory Information Management Systems
NCCLSLIS-9A Guide for Coordination of Clinical Laboratory Services within the Electronic Health Record Environment and Networked Architectures

Index Terms

Electronic Health Record (EHR) Systems; admission; discharge; Transfer (R-ADT) Systems; ambulatory care system; patient; data elements; health care; health care professionals; ICS Number Code 35.240.80

Citing ASTM Standards

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