ASTM E 1744 : 2004 : R2010
Withdrawn
A Withdrawn Standard is one, which is removed from sale, and its unique number can no longer be used. The Standard can be withdrawn and not replaced, or it can be withdrawn and replaced by a Standard with a different number.
Standard Practice for View of Emergency Medical Care in the Electronic Health Record (Withdrawn 2017)
Hardcopy , PDF
19-04-2017
English
01-03-2010
CONTAINED IN VOL. 14.01, 2015 Describes the information that is necessary to document emergency medical care in an electronic, paperless patient record system that is designed to improve efficiency and cost-effectiveness.
Committee |
E 31
|
DocumentType |
Standard Practice
|
Pages |
27
|
ProductNote |
Reconfirmed 2010
|
PublisherName |
American Society for Testing and Materials
|
Status |
Withdrawn
|
Supersedes |
1.1 This practice covers the identification of the information that is necessary to document emergency medical care in an electronic, paperless patient record system that is designed to improve efficiency and cost-effectiveness.
1.2 This practice is a view of the data elements to document the types of emergency medical information that should be included in the electronic health record.
1.2.1 The patient's summary record and derived data sets will be described separately from this practice.
1.2.2 As a view of the electronic health record, the information presented will conform to the structure defined in other ASTM standards for the electronic health record.
1.3 This practice is intended to amplify Guides E1239 and F1629 and the formalisms described in Practices E1384 and E1715.
1.3.1 This practice details the use of data elements already established in these standards and other national guidelines for use during documentation of emergency care in the field or in a treatment facility and places them in the context of the object models for health care in Practice E1384 that will be the vehicle for communication standards for health care data.
1.3.1.1 The data elements and the attributes referred to in this practice are based on national guidelines whenever available.
1.3.1.2 The EMS definitions are based on those generated from the previous EMS consensus conference sponsored by NHTSA and from ASTM task group F 30.03.03 on EMS Management Information Systems.
1.3.1.3 The Emergency Department (ED) definitions are based on the Data Elements for Emergency Department Systems (DEEDS) distributed by the Centers for Disease Control in June 1997.
1.3.1.4 The hospital discharge definitions are based on recommendations from the Centers for Medicare and Medicaid Services (CMS) for Medicare and Medicaid payment and from the Department of Health and Human Services for the Uniform Hospital Discharge Data Set.
1.3.1.5 Because the current trend is to store data as text, the codes for the attribute values have been determined as unnecessary and thus are eliminated from this document.
1.3.1.6 The ASTM process allows for the data elements to be updated as the national consensus changes. When national or professional guides do not exist, or whenever there is a conflict in the existing EMS, ED, hospital or other guides, the committee will recommend a process for resolving the conflict or an explanation of the conflict within each guide.
1.3.2 This practice reinforces the concepts set forth in Guide E1239 and Practice E1384 that documentation of care in all settings shall be seamless and be conducted under a common set of precepts using a common logical record structure and common terminology.
1.4 The electronic health record focuses on the patient.
1.4.1 In particular, the computer–based patient record sets out to ensure that the data document includes:
1.4.1.1 The occurrence of the emergency,
1.4.1.2 The symptoms requiring emergency medical treatment, and potential complications resulting from preexisting conditions,
1.4.1.3 The medical/mental assessment/diagnoses established,
1.4.1.4 The treatment rendered, and
1.4.1.5 The outcome and disposition of the patient after emergency treatment.
1.4.2 The electronic health record consists of subsets of data for the emergency patient that have been captured by different care providers at the time of treatment at the scene and en route, in the emergency department, and in the hospital or other emergency health care settings.
1.4.3 The electronic record focuses on the documentation of information that is necessary to support patient care but does not define appropriate care.
ASTM E 2473 : 2005 : R2011 | Standard Practice for the Occupational/Environmental Health View of the Electronic Health Record (Withdrawn 2020) |
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) |
IEEE 610.12-1990 | IEEE Standard Glossary of Software Engineering Terminology |
IEEE 729-1983 | IEEE Standard Glossary of Software Engineering Terminology |
ASTM E 2084 : 2000 | Standard Specification for Authentication of Healthcare Information Using Digital Signatures (Withdrawn 2009) |
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