ASTM E1239-2004 Standard Practice for Description of Reservation Registration-Admission Discharge Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems《电子健康记录系统用预约 登记.pdf

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1、Designation: E 1239 04An American National StandardStandard Practice forDescription of Reservation/Registration-Admission,Discharge, Transfer (R-ADT) Systems for Electronic HealthRecord (EHR) Systems1This standard is issued under the fixed designation E 1239; the number immediately following the des

2、ignation indicates the year oforiginal adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.1. Scope1.1 This practice identifies the

3、 minimum information capa-bilities needed by an ambulatory care system or a residentfacility R-ADT system. This practice is intended to depict theprocesses of: patient registration, inpatient admission intohealth care institutions and the use of registration data inestablishing and using the demogra

4、phic segments of theelectronic health record. It also identifies a common core ofinformational elements needed in this R-ADT process andoutlines those organizational elements that may use thesesegments. Furthermore, this guide identifies the minimumgeneral requirements for R-ADT and helps identify m

5、any ofthe additional specific requirements for such systems. The dataelements described may not all be needed but, if used, theymust be used in the way specified so that each record segmenthas comparable data. This practice will help answer questionsfaced by designers of R-ADT capabilities by provid

6、ing a cleardescription of the consensus of health care professionalsregarding a uniform set of minimum data elements used byR-ADT functions in each component of the larger system. Itwill also help educate health care professionals in the generalprinciples of patient care information management as we

7、ll asthe details of the constituent specialty areas.1.2 This standard does not purport to address all of thesafety concerns, if any, associated with its use. It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of

8、 regulatory requirements prior to use.2. Referenced Documents2.1 ASTM Standards:2E 1384 Practice for Description of Content and Structure ofElectronic Health Record SystemsE 1633 Specification for Coded Values Used in ElectronicHealth Record SystemsE 1714 Guide for Properties of a Universal Health I

9、dentifierE 1715 Practice for Object-Oriented Model for Registra-tion, Admitting, Discharge, and Transfer (R-ADT) Func-tions in Electronic Health Record SystemsE 1744 Guide for a View of Emergency Medical Care in theComputerized Medical RecordE 1869 Guide for Confidentiality, Privacy,Access, and Data

10、Principles for Health Information Including ElectronicHealth Records2.2 ANSI Standards:3ANS X3.38 Identification of States of the United States forInformation InterchangeANS X3.47 Structure of the Identification of Name Popu-lated Places and Related Entities of the States of theUnited StatesNCCLS LI

11、S-5A Specification for Transferring Clinical Ob-servations Between Independent Computer SystemsNCCLS LIS-8A Guide for Functional Requirements ofClinical Laboratory Information Management SystemsNCCLS LIS-9A Guide for Coordination of Clinical Labo-ratory Services within the Electronic Health Record E

12、n-vironment and Networked Architectures2.3 ISO Standards:4ISO 639 Names of LanguagesISO 3166 Names of CountriesISO 5218 Representation of Human Sexes1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.25 on Heal

13、thcareData Management, Security, Confidentiality, and Privacy. This guide was preparedin collaboration with the American Health Information Management Assn.Current edition approved Nov. 1, 2004. Published November 2004. Originallyapproved in 1988. Last previous edition approved in 2000 as E 1239 00.

14、2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3Available from American National Standards Institute (ANSI),

15、 25 W. 43rd St.,4th Floor, New York, NY 10036.4Available from ISO.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.2.4 Federal Information Processing Standard Publication:5FIPSPUB 6-2 Counties of the States of the United StatesFIPSPUB

16、 5-1 States of the United States3. Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 admissionformal acceptance by a hospital of apatient who is to be provided with room, board, and continuousnursing services in an area of the hospital where patientsgenerally stay overnight.3.1.2 b

17、asic data set for ambulatory caredata items whichconstitute the minimum basic set of data that should be enteredin the record concerning all ambulatory medical care encoun-ters.3.1.3 clinic outpatientadmitted to a clinical service of ahospital for diagnosis or therapy on an ambulatory basis in aform

18、ally organized unit of a medical or surgical specialty orsubspecialty. The clinic assumes overall medical responsibilityfor the patient.3.1.4 dischargetermination of a period of inpatient hos-pitalization through the formal release of the inpatient by thehospital.3.1.5 dispositiondirecting of a pati

19、ent from oneenvironment/health care delivery mode to another at conclu-sion of services.3.1.6 emergency patientadmitted to emergency room ser-vice of a hospital for diagnosis and therapy of a condition thatrequires immediate medical, dental, or allied services.3.1.7 encounterface-to-face contact bet

20、ween a patient anda provider who has primary responsibility for assessing andtreating the patient at a given contact, exercising independentjudgment.3.1.8 inpatientan individual receiving, in person, residenthospital-based or coordinated medical services for which thehospital is responsible.3.1.9 in

21、patient episodeperiod of time in which the patientis in an inpatient status, beginning with admission and termi-nating with discharge.3.1.10 master patient indexpermanent listing that revealsidentity and location of patients treated by a health care facility.3.1.11 outpatientan individual receiving,

22、 in person, non-resident, provider-supplied or coordinated medical services forwhich the provider is responsible. The types of outpatientsrecognized are:3.1.11.1 Emergency3.1.11.2 Clinic, and3.1.11.3 Referred.3.1.12 patient care recordlegal documented record ofhealth care services provided by a heal

23、th care facility. Synony-mous with: medical record, health record, patient record.3.1.13 practitioner specialtyfor a particular practitioner,the subject area of health care or scope of health care servicesin which the major share of his or her practice is carried out.See National Provider System Tax

24、onomy in SpecificationE 1633.3.1.14 registrationrecording the patient demographic andfinancial data in a unit record for patient care or a billing recordfor charge capture, respectively.3.1.15 referred outpatientadmitted exclusively to a spe-cial diagnostic/therapeutic service of the hospital for di

25、agnosis/treatment on an ambulatory basis. Responsibility remains withthe referring physician.3.1.16 specialty typeclassification of specialized fields ofmedical services, such as, for example, Gynecology, GeneralSurgery, Orthopedic Surgery, etc.3.1.17 transferchange in medical care unit, medical sta

26、ff,or responsible physician of an inpatient during hospitalization.3.1.18 uniform hospital discharge data setThose essentialdata elements which should be recorded to provide a compositepicture of the patients stay.3.2 Acronyms:CPR Computer-based Patient RecordEHR Electronic Health RecordR-ADT Regist

27、ration-Admission, Discharge, TransferADT Admittng, Discharge, TransferR-RADT Registration/Reservation-Admitting, Discharge,TransferMPI Master Patient/Person Index4. Significance and Use4.1 Background:4.1.1 Effective health care delivery requires an efficientinformation base. A standard description i

28、s needed regardingthe capabilities of Registration-Admission, Discharge, Transfer(R-ADT) Systems in both automated hospital and ambulatorycare information systems. This practice is intended not only toprovide a common explanation of the minimum informationelements required in such systems, thus augm

29、enting thosealready published6,7but also to provide the basis for futurepatient data interchange formats. This practice has been devel-oped to serve as a uniform minimum description of R-ADTfunctional components that should be common in all systemsand used in both transportable general purpose and c

30、ustomdeveloped systems. This description requires acceptance of thepremise regarding the need for logical integration of conceptsin systems development. In the integrated systems concept, theR-ADT function is the foundation module for all patientinformation and communication among all departments, a

31、nd itis used in initiating services within the patient care setting. Acommon R-ADT system in a hospital enables all departmentsto streamline the initiation and tracking of the services theyprovide to patients; it also provides an opportunity for accuratetracking of patient movement throughout a hosp

32、ital stay, forinstance, and the linkage of inpatient and outpatient services. Itis also the system which provides all inpatient census-relatedadministrative reports. Likewise, an R-ADT component in anEnterpriseArchitecture captures the initial patient demographicprofile for the EHR and is subsequent

33、ly accessed in posting anindividuals clinical data, for inquiry regarding that clinicaldata and for linkage to financial records. It is an integral part of5Available from US Dept. of Commerce, Government Printing Office, Wash-ington, DC.6Uniform Ambulatory Medical Care: Minimum Data Set, DHHS Public

34、ationPHS 81-1161, DHHS National Center for Health Statistics, 1981.7Uniform Hospital Discharge Data Set, DHHS Publication HSM 74-1451,Health Information Policy Council DHHS, 1984.E1239042the EHR function. It may also be linked to other systems whichprovide patient care information management capabil

35、ities.4.1.2 A registration system is capable of providing theinitial information capture for all health care facilities; anADTsubsystem can provide common admitting data for all depart-ments in hospitals and other inpatient facilities. Establishing astandard description of a logical R-ADT process mo

36、del isuseful because that standard will become a reference for otherdocuments describing the other functional subsystems used inpatient care information systems. It is understood that aminimum set of information elements must be initially cap-tured upon registration and then used for all subsequenta

37、mbulatory or inpatient care; the subsequent minimum set ofadmitting elements is then used to drive or initiate additionalservices for patients through each subsystem. With a standardminimum R-ADT component definition, standards for con-stituent subsystems can now be coordinated and developedthrough

38、reference to this model. This description should beused by vendors and subsystem designers who need to developtheir systems in a coordinated and integrated way so that eachsubsystem will contribute modularly with overall systemsplanning for the user organization. Such modularity will aidmanagement w

39、ho are assigned to evaluate each system andsubsystem in order to assess the potential of existing technol-ogy to provide the needed patient care information manage-ment systems capabilities.4.2 UseThis practice is written assuming that the healthcare facility will have several options for gaining th

40、e R-ADTcapability and may either acquire a system from a commercialvendor or design an integrated in-house system which may bea component of an ambulatory care practice or a hospitalinformation system. Many of the characteristics of existingvendor systems are conventional and can interoperate; the c

41、arefacility may simply need to identify whether or not the offeredfeatures meet its needs. Beyond the general capabilities, theunique systems capabilities can then be identified and struc-tured to meet the special needs of that individual enterprise. Amore accurate selection can therefore be made fr

42、om thefeatures offered by vendors if each health care facility/hospitalcarefully identifies its own R-ADT functional requirementswith the aid of this guide prior to evaluating candidate systemsor development approaches and specifying that these require-ments be met.4.3 Role of R-ADT Systems in Integ

43、rated DeliverySystemsRegistration/Reservation-Admission, Discharge.Transfer functions in integrated delivery systems need toprovide a uniform enterprise view with data accessible acrossthe IDS. Typical functions in this environment may includeregistration to an enterprise master patient index, repor

44、tingcapabilities on R-ADT functions, enterprise scheduling andenterprise capabilities for eligibility and utilization manage-ment. Patient data collected should be transferable to medicalrecord abstract applications and contribute to clinical reposi-tories to maintain longitudinal focus to evolve to

45、ward elec-tronic health records. IDS networks provide infrastructure andshould conform to enterprise technical security requirementsthat meet legal and accreditation requirements.5. System Description5.1 General Principles and PurposeThe purposes of anR-ADT system are to:5.1.1 Identify or verify pat

46、ients, or both, via a facility masterpatient index created and maintained through the registrationprocess.5.1.2 Establish an initial record of the patient entry into thesystem by creating the demographic segment of the EHR(registration).5.1.3 Maintain the registration record and demographic dataas a

47、 common node for patient care record systems so that it canbe used by all ancillary support systems.5.1.4 Augment the registration record by addition of thosedata required for any inpatient admission.5.1.5 Initiate services for all inpatients admitted to thefacility by providing notification of the

48、start of services.5.1.6 Track movements of the inpatient throughout hospi-talization.5.1.7 Facilitate scheduling of ancillary and clinical servicesthrough a bed control and transfer function.5.1.8 Produce the inpatient census data and the correspond-ing census and statistical reports.5.1.9 Identify

49、movement, location, status, and discharge ofeach in-patient and the times and dates of these events, thishelps coordinate efficient support services for treating thatpatient during hospitalization. This is achieved by means ofcensus reporting and afterwards during follow-up care bymeans of linkage to the care record.5.1.10 Offer all departments of the health care facilitycommon information about each registered/admitted patientthrough maintenance of a single registration record, thuseliminating duplicative patient data capture by those depart-ments.5.1.11 Produ