ASTM E2184

This specification addresses requirements for the headings, arrangement, and appearance of sections and subsections when used within an individual's healthcare documents. This specification will facilitate identification and retrieval of health information in a manner that will enhance the quality and efficiency of health services. Use of this specification in conjunction with XML DTDs (extensible markup language document type definitions) and the EHR (electronic health records) would further enhance efficiency in time and cost. In addition, this specification applies across multiple healthcare settings in which healthcare documents are generated, such as hospitals, clinics, skilled nursing facilities, ambulatory care facilities, outpatient surgery centers, and private healthcare providers' offices. The author of a healthcare document may choose to summarize subsection information within a general section rather than creating subsections.

This abstract is a brief summary of the referenced standard. It is informational only and not an official part of the standard; the full text of the standard itself must be referred to for its use and application. ASTM does not give any warranty express or implied or make any representation that the contents of this abstract are accurate, complete or up to date.

1. Scope

1.1 This specification addresses requirements for the headings, arrangement, and appearance of sections and subsections when used within an individual's healthcare documents. This specification will facilitate identification and retrieval of health information in a manner that will enhance the quality and efficiency of health services. Use of this specification in conjunction with XML DTDs (extensible markup language document type definitions) and the EHR (electronic health records) would further enhance efficiency in time and cost. This specification applies across multiple healthcare settings in which healthcare documents are generated, such as hospitals, clinics, skilled nursing facilities, ambulatory care facilities, outpatient surgery centers, and private healthcare providers' offices.

1.2 This specification addresses the headings, arrangement, and appearance of sections and subsections of healthcare documents, however generated (dictation/transcription, speech recognition, touch-screen entry, and so forth) and whether displayed electronically or on paper. It does not address the titles of healthcare documents or the content of sections and subsections.

1.2.1 The author of a healthcare document may choose to summarize subsection information within a general section rather than creating subsections.

1.3 The format and content of patient-identifying data are addressed in Guide E 1384.

1.4 Issues of confidentiality and security are addressed in Guide E 1869, Guide E 1902, Guide E 1762, Guide E 1985, Guide E 1986, Guide E 1987, Guide E 1988, Specification E 2084, Guide E 2085, and Guide E 2086, as well as in Specification E 2147.

1.5 Issues of XML DTDs are addressed in Specification E 2182 and Guide E 2183.

2. Referenced Documents

E1384 Guide for Content and Structure of the Electronic Health Record (EHR)
E1762 Guide for Electronic Authentication of Health Care Information
E1869 Guide for Confidentiality, Privacy, Access, and Data Security Principles for Health Information including Computer-Based Patient Records
E1902 Guide for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records
E1985 Guide for User Identification and Authorization
E1986 Guide for Information Access Privileges to Health Information
E1987 Guide for Individual Rights Regarding Health Information
E1988 Guide for Training of Persons Who Have Access to Health Information
E2147 Specification for Audit and Disclosure Logs for use in Health Information Systems
E2182 Specification for Clinical XML DTDs in Healthcare
E2183 Guide for XML DTD Design, Architecture, and Implementation

Index Terms

appearance; arrangement; format; headings; healthcare document; sections; subsections; ICS Number Code 35.240.80 (IT applications in health care technology)

Citing ASTM Standards

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