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ASTM E 1384 : 1999 : EDT 1

Withdrawn
Withdrawn

A Withdrawn Standard is one, which is removed from sale, and its unique number can no longer be used. The Standard can be withdrawn and not replaced, or it can be withdrawn and replaced by a Standard with a different number.

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withdrawn

A Withdrawn Standard is one, which is removed from sale, and its unique number can no longer be used. The Standard can be withdrawn and not replaced, or it can be withdrawn and replaced by a Standard with a different number.

Standard Guide for Content and Structure of the Electronic Health Record (EHR)
Available format(s)

Hardcopy , PDF

Withdrawn date

03-31-2017

Language(s)

English

Published date

11-10-2001

1.1 This guide covers all types of healthcare services, including those given in acute care hospitals, nursing homes, skilled nursing facilities, home healthcare, and specialty care environments as well as ambulatory care. 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). At this time, the standard vocabulary reflects more traditional care. As the standard evolves in the next revisions, the vocabulary will more adequately encompass the entire continuum of care through all delivery models, health status measurement, preventive case, and health education content.

1.2 This guide has five purposes. The first is to identify the content and logical structure of a Electronic Health Record (EHR). The record carries all health related information about a patient over time. It includes such things as observations or descriptions of the patient (for example, the physician's or nurse practitioner's history and physical, laboratory tests, diagnostic imaging reports), provider's orders for observations and treatments, documentation about the actions carried out (for example, therapies or drugs administered), patient identifying information, legal permissions, and so on.

1.2.1 The second goal is to define the relationship of data coming from diverse source systems (for example, clinical laboratory information management systems, order entry systems, pharmacy information management systems, dictation systems), and the data stored in the Electronic Health Record. Recalling that the EHR is the primary repository for information from various sources, the structure of the EHR is receptive to the data that flow from other systems.

1.2.2 Third, in order to accelerate the adoption of EHRs, this guide provides a common vocabulary, perspective, and references for those developing, purchasing, and implementing EHR systems, but it does not deal either with implementation or procurement.

1.2.3 Fourth, this guide describes examples of a variety of views by which the logical data structure might be accessed/displayed in order to accomplish various functions.

1.2.4 Fifth, this guide relates the logical structure of the EHR to the essential documentation currently used in the healthcare delivery system within the United States in order to promote consistency and efficient data transfer. It maps to the clinical data currently in existing data systems and patient care records.

Committee
E 31
DocumentType
Guide
Pages
102
PublisherName
American Society for Testing and Materials
Status
Withdrawn
SupersededBy

ASTM E 1959 : 2005 : R2011 Standard Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions (Withdrawn 2020)
ASTM E 2369 : 2012 Standard Specification for Continuity of Care Record (CCR) (Withdrawn 2021)
ASTM E 1714 : 2007 : R2013 Standard Guide for Properties of a Universal Healthcare Identifier (UHID) (Withdrawn 2022)
ASTM E 2473 : 2005 : R2011 Standard Practice for the Occupational/Environmental Health View of the Electronic Health Record (Withdrawn 2020)
ASTM E 2522 : 2007 : R2013 Standard Guide for Quality Indicators for Health Classifications (Withdrawn 2022)
ASTM E 2538 : 2006 : R2011 Standard Practice for Defining and Implementing Pharmacotherapy Information Services within the Electronic Health Record (EHR) Environment and Networked Architectures (Withdrawn 2020)
ASTM E 2457 : 2007 : R2013 Standard Terminology for Healthcare Informatics (Withdrawn 2022)

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US$152.00
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