ASTM E1633-2008a(2013) Standard Specification for Coded Values Used in the Electronic Health Record《用于电子健康档案的编码数值的标准规范》.pdf

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1、Designation: E1633 08a (Reapproved 2013) An American National StandardStandard Specification forCoded Values Used in the Electronic Health Record1This standard is issued under the fixed designation E1633; the number immediately following the designation indicates the year oforiginal adoption or, in

2、the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope*1.1 This specification covers the identification of the lexi-cons to be used for the da

3、ta elements identified inAppendix X1of Guide E1384. It is intended to unify the representations for:(1) primary record of care data elements, (2) the data elementsidentified in other standard statistical data sets, (3) dataelements used in other healthcare data message exchangeformat standards, or (

4、4) in data gathering forms for thispurpose, and (5) in data derived from these elements in orderthat data recorded in the course of patient care be exchangeableand be the source of accurate statistical and resource manage-ment data. This specification is applicable to all paper andautomated systems.

5、2. Referenced Documents2.1 ASTM Standards:2E1238 Specification for Transferring Clinical ObservationsBetween Independent Computer Systems (Withdrawn2002)3E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) System

6、sE1384 Practice for Content and Structure of the ElectronicHealth Record (EHR)E1715 Practice for An Object-Oriented Model forRegistration, Admitting, Discharge, and Transfer (RADT)Functions in Computer-Based Patient Record SystemsE1744 Practice for View of Emergency Medical Care in theElectronic Hea

7、lth Record2.2 ANSI Standards:4ANS X3.50 Representation of Date and TimeANS X3.51 Representation of Common Units2.3 ISO Standards:4ISO 639 Names of LanguagesISO 2955 Representation of SI UnitsISO 3166 Names of CountriesISO 5218 Representation of Human SexesISO 8601 Representation Dates2.4 Other Stand

8、ards:HL-7 Health Industry Level 7 Interface Standards53. Terminology3.1 Acronyms:3.1.1 NCHSNational Center for Health Statistics3.1.2 NCVHSNational Committee for Vital and HealthStatistics3.1.3 NOSnot otherwise specified4. Significance and Use4.1 PurposeThe approval of Guide E1384, concernedwith the

9、 structure and content of the computer-based patientrecord, now includes a formal indexing of data elements and acataloging of the minimal essential value set for these ele-ments. Indexing of these data elements with a unique identifierkeyed to its position in the logical structure of Appendix X1 of

10、Guide E1384 now provides a means of cataloging the valuesets representing each data element (see Guide E1384). Speci-fication E1238, coordinated with Guide E1239, describesconventions for representing many of the data values for dataelements that are included in the more comprehensive listing inGuid

11、e E1384. A comprehensive listing of all of the value setsassociated with Guide E1384 has not yet been assembled. Thisspecification begins to catalog the representation conventionsfor a number of these elements and in particular to list thecoded values. It is important that this catalog consider thet

12、raditionally assigned representations for each of theseelements, and it must resolve differences in a manner thatintroduces systematics and consistency into the representation.The catalog must establish both a global framework consistentwith international standardization and with long-term growth,wh

13、ile at the same time maximizing familiar or traditionalrepresentations. This standard has been developed with input1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data Management, Securi

14、ty, Confidentiality, and Privacy.Current edition approved April 15, 2013. Published April 2013. Originallyapproved in 1996. Last previous edition approved in 2008 as E163308a. DOI:10.1520/E1633-08AR13.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Servi

15、ce at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from American National Standards Institute (ANSI), 25 W. 43rd St.

16、,4th Floor, New York, NY 10036, http:/www.ansi.org.5Available from Health Level 7, Mark McDougall, Executive Director, 900Victors Way, Suite 122, Ann Arbor, MI 48108.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive, PO Box C700, Wes

17、t Conshohocken, PA 19428-2959. United States1from many organizations, including government agencies andother standards bodies and professional associations, and as aresult of the effort to achieve consistency and comprehensive-ness among the data dealt with by various standards efforts.4.2 General V

18、alues Early in the coordination of healthcareinformation standards an informal body, the Healthcare Infor-mation Standards Coordinating Committee (HISCC), identifiedcertain common data element types and agreed upon conven-tions for representing these data element types in a standardmanner. This set

19、the stage for the development of the value setsfor the CODED VALUE data type. The status of the standardnoncoded data types, and their representations, agreed upon bythe HISCC are:4.2.1 Person Names Specification E1238, Guide E1239,Practice E1715, Practice E1744, and HL-7 use the samerepresentation

20、for American and European forms.4.2.2 AddressesCommon format in Specification E1238,Guide E1239, Practice E1715, and Practice E1744. E1239.4.2.3 Telephone NumbersSpecification E1238 and GuideE1239 currently use the same representation with area codeenclosed in parentheses and country code preceding

21、the paren-theses.4.2.4 DatesDate and time represented as ANS X3.51-1986/ISO 8601-1988 with years in four digits; time notseparated from date by “T” as permitted by ISO 8601.4.2.5 NumbersNumbers are represented either as integersor fixed point numbers; exponential notation not presentlyaccepted in Sp

22、ecification E1238, Guide E1239, or HL-7. Unitsof Measure by ISO 2955-1983 or ANS X3.50-86.4.2.6 Strings7-bit ASCII characters; multilingual charac-ter sets not yet defined.65. Assignment of Coded Values5.1 The major important data elements in Guide E1384having coded data types and the current status

23、 of the catalogingof their values are:01035 Patient Multiple Birth code (5.2.23)01040 Sex (5.2.20)01042 Biogeographic Ancestry (Race) (5.2.3)01045 Ethnicity (5.2.4)01047 Religion (5.2.7)01052 Marital status (5.2.2)01055 Nationality/Country of Origin (5.2.6)01057 Language (5.2.5)01060 Educational Lev

24、el (5.2.8)Educational Certification (5.2.9)01062 Current Work Status (5.2.24)01065 Occupation (5.2.11) also 01070,01090.0301067 Current Vocational Status (5.2.25)01085 Usual Living arrangement (5.2.26)01099 Foreign Residency Code (5.2.27)01090.03 Family Relationship (5.2.10)01155 Color Eyes (5.2.38)

25、01160 Color Hair (5.2.39)01175 Body Build for Identification (5.2.40)02052 Durable Power of Attorney Status (5.2.28)06001.01.15 Immunization reaction/result (5.2.63)04001.50 Professional Specialty (5.2.16)08005 Birth method (5.2.64)08095 Health History Response (5.2.76)09001.12 Body System/Region (5

26、.2.22)09001.13 Exam Finding (5.2.77)09001.30 Tooth ID (5.2.74)09001.30.05 Tooth Surface (5.2.75)09001.30.06 Tooth Sensitivity Code (5.2.65)09001.30.07 Tooth Mobility Code (5.2.66)09001.40.1 Prosthesis Type (5.2.67)11001.01.24 Test Specimen Source (5.2.68)14001.A002 Patient (Encounter) Type/Admission

27、 Source (5.2.17)14001.A004 Confidentiality Status (5.2.1)14001.A010 Encounter Status (5.2.69)14001.A013 Facility Care/Healthcare setting (5.2.18)14001.A016 Reason for Visit (5.2.19)14001.A020 Encounter patient Arrival Condition (5.2.70)14001.A021 Mode of Arrival (5.2.29)14001.A030 Nature of Injury (

28、5.2.30)14001.A033 Mode of Injury (5.2.31)14001.A034 Product of Injury (5.2.37)14001.A040 Injury On the Job Status (5.2.71)14001.A044 Protective Equipment Used (5.2.32)14001.A063 Patient Admission Type (5.2.12)14001.A110 Professional Specialty (5.2.16)14001.A133 Accommodation type (5.2.15)14001.A163.

29、01 Patient In-residence Transfer Type (5.2.13)14001.A170 Diagnosis (5.2.33)14001.A170.01 Diagnosis Type (5.2.34)14001.A170.02 Diagnosis Status Code (5.2.35)14001.A186.01 Current Clinical Status (5.2.36)14001.A206 Police Hold Status (5.2.72)14001.A213 Medical Examiner Notification Code (5.2.73)14001.

30、A223 Source of Payment Code (5.2.21)14001.F050 Discharge Disposition Category (5.2.14)This standard identifies the current value list for each ofthese elements as of the approval date of this standard (seefootnote 1) and states the evolving status of this catalog as theknowledge of the use of these

31、elements expands as a result ofongoing investigation. Each element is identified by the indexassigned to it in the revised Appendix X1 of Guide E1384.Moreover, the definition for that element from the DataElement Catalog (5) is included with the value set.5.2 Value Set TablesThese tables collect the

32、 representationof coded data values for specific data elements in computer-based patient record structures identified in Appendix X1 ofGuide E1384. The terms listed here are the minimal essentialones but may be further subclassified to include more specificterms by appropriate extensions of the incl

33、uded terms.5.2.1 Confidentiality StatusThis data element, Index:14001.A004, contains the minimal commonly used valuesappearing in both manual and automated systems. See Speci-fication E1238.Unwed mother UWMCelebrity VIPPsychiatric patient PSYEmployee EMPAIDS patient AIDHIV patient HIVAlcohol/Drug pa

34、tient ETHUsual control URestricted RVery restricted V5.2.2 Marital StatusThis data element, Index: 01052,encompasses the values noted by Westermeyer (6), Bureau ofCensus, the VA DHCP system, the DoD CHCS system, theX12 835 Transaction Set (7) , UB-82 (8), and used in commonpractice.Never married BSi

35、ngle SMarried M6The boldface numbers in parentheses refer to the list of references at the end ofthis standard.E1633 08a (2013)2Divorced DDivorced/annulled LDivorced/separated HAnnulled NWidowed WSeparated, NOS ASeparated, legal ESeparated, nonlegal KMarriage, separation, temporary absence XMarriage

36、, separation, permanent absence VConsensual union JUnknown UCommon Law CDomestic Partner PRegistered Domestic Partner RLiving together GInterlocutory IOther OUnreported T5.2.3 Biogeographic Ancestry (previously stated as:Race)This data element, Index: 01042, indicates the re-gion of the world from w

37、hich the patients ancestors came.This is a biologic attribute that very generally indicatespossible biologic diversity to which the patient might besubject. Due to ambiguity inherent in the diversity of the largenumber of inherited attributes which might characterize suchancestry, other data element

38、s of the care record will be requiredto assign full meaning to the value set recorded for thisattribute. The name originates from recommendations in thegenetics literature (Am J Hum Gent 77:519-532 2005).Therefore, utilization of these other attributes is stronglyrecommended. To be consistent with c

39、ensus data, the six valuescurrently given in OMB Directive 15 are shown for relation-ship to the recommended new terms. New subcategories maybe added as recommended by the genetics professional disci-plines. The check digit for the code is calculated via programpreviously given in Specification E123

40、8 and shown in Appen-dix X1. Note that NOS in the term means “Not OtherwiseSpecified.”Proposed Term Code Present TermAFRICA:NOS 2054-5 BLACKAFRICA:WEST AFRICA 0218-AFRICA:CENTRALSUB-SAHARAN AFRICA0219-AFRICA:EAST AFRICA 0220-AFRICA:SOUTHERN AFRICA 0221-AMERICA:NOS 1002-5 AMERICAN INDIAN/ALASKA NATIV

41、EAMERICA:NORTH AMERICA(ABORIGINAL)0222-AMERICA:CENTRAL AMERICA/CARIBBEAN (ABORIGINAL)0223-AMERICA:SOUTH AMERICA 0224-EAST ASIA:NOS 2028-9 ASIANEAST ASIA:CENTRAL ASIA 0225-EAST ASIA:NORTHERN ASIA 0226-EAST ASIA:EAST ASIA 0227-EAST ASIA:SOUTH ASIA 0228-EAST ASIA:SOUTHEAST ASIA 0229-EAST ASIA:AUSTRALIA

42、 (ABORIGINAL) 0230-EURASIA:NOS 2106-3 WHITEEURASIA:WESTERN EUROPE 0231-EURASIA:NORTHERN EUROPE 0232-EURASIA:EASTERN EUROPE 0233-EURASIA:SOUTHERN EUROPE/MEDITERANIAN0234-EURASIA:NORTH AFRICA 0235-EURASIA:NEAR EAST 0236-EURASIA:ARABIAN PENINSULA 0237-EURASIA:WESTERN EURASIA 0238-OCEANIA:NOS 2076-8 HAW

43、AIIAN/PACIFIC ISLANDEROCEANIA:PACIFIC ISLANDS 0239-OTHER 2131-35.2.4 EthnicityIn keeping with current demographicpractice, this data element, Index: 01045, reflects the ethniccultural group with which the patient identifies. Multipleselections may be made. Each value has associated with it anancestr

44、al cultural origin tag that is most closely associated withthe ancestral geographic origin of that cultural pattern. This tagdoes not signify the ancestral biologic characteristics of theindividual which is recorded in other data elements of therecord. See Fig. 1.5.2.5 LanguageThis data element, Ind

45、ex 01058, is speci-fied by the two character lower case code in ISO 639 Table 1.The upper case three character code, now in ISO balloting maybe added in a future revision of this specification. The languagesymbol only is shown here, but an original name and Frenchlanguage name are available (see Fig

46、. 2 for list).E1633 08a (2013)35.2.6 Nationality/Country of Origin This data element,Index: 01055, Citizenship, is specified by ISO 3166. The twoletter codes are shown here. A three letter and a numeric codeexists for each entry. New entries may be added in the future.FIG. 1 Ethnic GroupE1633 08a (2

47、013)4FIG. 1 Ethnic Group (continued)E1633 08a (2013)5FIG. 1 Ethnic Group (continued)E1633 08a (2013)6FIG. 1 Ethnic Group (continued)E1633 08a (2013)7FIG. 1 Ethnic Group (continued)E1633 08a (2013)8FIG. 1 Ethnic Group (continued)E1633 08a (2013)9FIG. 1 Ethnic Group (continued)E1633 08a (2013)10FIG. 1

48、 Ethnic Group (continued)E1633 08a (2013)11FIG. 1 Ethnic Group (continued)E1633 08a (2013)12FIG. 1 Ethnic Group (continued)E1633 08a (2013)13FIG. 1 Ethnic Group (continued)E1633 08a (2013)14FIG. 1 Ethnic Group (continued)E1633 08a (2013)15FIG. 1 Ethnic Group (continued)E1633 08a (2013)16FIG. 1 Ethni

49、c Group (continued)E1633 08a (2013)17FIG. 1 Ethnic Group (continued)E1633 08a (2013)18FIG. 1 Ethnic Group (continued)E1633 08a (2013)19FIG. 1 Ethnic Group (continued)E1633 08a (2013)20FIG. 1 Ethnic Group (continued)E1633 08a (2013)21FIG. 1 Ethnic Group (continued)E1633 08a (2013)22FIG. 1 Ethnic Group (continued)E1633 08a (2013)23FIG. 1 Ethnic Group (continued)E1633 08a (2013)24FIG. 1 Ethnic Group (continued)E1633 08a (2013)25FIG. 2 Language ListE1633 08a (2013)26FIG. 2 Language List (continued)E1633 08a (2013)27FI