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Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this practice was withdrawn in March 2017. This standard is being withdrawn without replacement due to its limited use by industry.
1.1 This practice covers all types of healthcare services, including those given in ambulatory care, hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments. They apply both to short term contacts (for example, emergency rooms and emergency medical service units) and long term contacts (primary care physicians with long term patients). The vocabulary aims to encompass the continuum of care through all delivery models. This practice defines the persistent data needed to support Electronic Health Record system functionality.
1.2.1 Identify the content and logical data structure and organization of an Electronic Health Record (EHR) consistent with currently acknowledged patient record content. The record carries all health related information about a person over time. It may include history and physical, laboratory tests, diagnostic reports, orders and treatments documentation, patient identifying information, legal permissions, and so on. The content is presented and described as data elements or as clinical documents. This standard is consistent with eXtensible Markup Language (XML). See Document Type Definition (DTD) 2.1 and W3CXML Schema 1.0
1.2.2 Explain the relationship of data coming from diverse sources (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and other data in the Electronic Health Record as the primary repository for information from various sources.
2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.
E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems
E1633 Specification for Coded Values Used in the Electronic Health Record
E1639 Guide for Functional Requirements of Clinical Laboratory Information Management Systems
E1714 Guide for Properties of a Universal Healthcare Identifier (UHID)
E1715 Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
E1769 Guide for Properties of Electronic Health Records and Record Systems
E2118 Guide for Coordination of Clinical Laboratory Services within the Electronic Health Record Environment and Networked Architectures
E2369 Specification for Continuity of Care Record (CCR)
E2473 Practice for the Occupational/Environmental Health View of the Electronic Health Record
E2538 Practice for Defining and Implementing Pharmacotherapy Information Services within the Electronic Health Record (EHR) Environment and Networked Architectures
Other Health Informatics StandardsANSI ASC X12: Version 3, Release 3 (1992) Available from DISA (Data Interchange Standards Association). HL7 Health Level Seven (HL7) Version 2.2 1994 Available from HL7, Mark McDougall, Executive Director, 900 Victors Way, Suite 122, Ann Arbor, MI 48108. (Version 2.4 and 2.5) NCPDP National Council for Prescription Drug Prog Release 2, 1992 Available from NCPDP, 4201 North 24th Street, Suite 365, Phoenix, AZ 85016. X12.84 Healthcare Enrollment and Maintenance Transaction Set (834) Available from American National Standards Institute (ANSI), 25 W. 43rd St., 4th Floor, New York, NY 10036. X12.85 Healthcare Claim Payment Transaction Set (835) X12.87 Healthcare Claim Transaction Set (837)
ANSI StandardsHealth Information Management and Technology: Glossary, American Health Information Management Association, 2006 HL7 EHR TC Electronic Health Record-System Functional Model, Release 1 February, 2007
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ASTM E1384-07(2013), Standard Practice for Content and Structure of the Electronic Health Record (EHR) (Withdrawn 2017), ASTM International, West Conshohocken, PA, 2013, www.astm.orgBack to Top