ASTM E1744-2004 Standard Practice for View of Emergency Medical Care in the Electronic Health Record《电子健康记录中急症治疗观测的标准规程》.pdf

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1、Designation: E 1744 04An American National StandardStandard Practice forView of Emergency Medical Care in the Electronic HealthRecord1This standard is issued under the fixed designation E 1744; the number immediately following the designation indicates the year oforiginal adoption or, in the case of

2、 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 covers the identification of the informationthat is necessary to document emerge

3、ncy medical care in anelectronic, paperless patient record system that is designed toimprove efficiency and cost-effectiveness.1.2 This practice is a view of the data elements to documentthe types of emergency medical information that should beincluded in the electronic health record.1.2.1 The patie

4、nts summary record and derived data setswill be described separately from this practice.1.2.2 As a view of the electronic health record, the infor-mation presented will conform to the structure defined in otherASTM standards for the electronic health record.1.3 This practice is intended to amplify G

5、uides E 1239 andF 1629 and the formalisms described in Practices E 1384 andE 1715.1.3.1 This practice details the use of data elements alreadyestablished in these standards and other national guidelines foruse during documentation of emergency care in the field or ina treatment facility and places t

6、hem in the context of the objectmodels for health care in Practice E 1384 that will be thevehicle for communication standards for health care data.1.3.1.1 The data elements and the attributes referred to inthis practice are based on national guidelines whenever avail-able.1.3.1.2 The EMS definitions

7、 are based on those generatedfrom the previous EMS consensus conference sponsored byNHTSA and from ASTM task group F 30.03.03 on EMSManagement Information Systems.1.3.1.3 The Emergency Department (ED) definitions arebased on the Data Elements for Emergency Department Sys-tems (DEEDS) distributed by

8、the Centers for Disease Controlin June 1997.1.3.1.4 The hospital discharge definitions are based onrecommendations from the Centers for Medicare and MedicaidServices (CMS) for Medicare and Medicaid payment and fromthe Department of Health and Human Services for the UniformHospital Discharge Data Set

9、.1.3.1.5 Because the current trend is to store data as text, thecodes for the attribute values have been determined as unnec-essary and thus are eliminated from this document.1.3.1.6 The ASTM process allows for the data elements tobe updated as the national consensus changes. When nationalor profess

10、ional guides do not exist, or whenever there is aconflict in the existing EMS, ED, hospital or other guides, thecommittee will recommend a process for resolving the conflictor an explanation of the conflict within each guide.1.3.2 This practice reinforces the concepts set forth in GuideE 1239 and Pr

11、actice E 1384 that documentation of care in allsettings shall be seamless and be conducted under a commonset of precepts using a common logical record structure andcommon terminology.1.4 The electronic health record focuses on the patient.1.4.1 In particular, the computerbased patient record setsout

12、 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 treat-ment, and potential complications resulting from preexistingconditions,1.4.1.3 The medical/mental assessment/diagnoses estab-lished,1.4.1.4 The treatment rendered

13、, and1.4.1.5 The outcome and disposition of the patient afteremergency treatment.1.4.2 The electronic health record consists of subsets of datafor the emergency patient that have been captured by differentcare providers at the time of treatment at the scene and enroute, in the emergency department,

14、and in the hospital or otheremergency health care settings.1.4.3 The electronic record focuses on the documentation ofinformation that is necessary to support patient care but doesnot define appropriate care.1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and

15、is the direct responsibility of Subcommittee E31.25 on HealthcareManagement, Security, Confidentiality, and Privacy.Current edition approved Nov. 1, 2004. Published November 2004. Originallyapproved in 1995. Last previous edition approved in 1998 as E 1744 98.1Copyright ASTM International, 100 Barr

16、Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.2. Referenced Documents2.1 ASTM Standards:2E 1239 Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (RADT) Systems for Au-tomated Patient Care Information SystemsE 1384 Practice for Description

17、of Content and Structure ofan Automated Primary Record of CareE 1633 Specification for Coded Values Used in theComputer-Based Patient RecordE 1715 Practice for an Object-Oriented Model for Registra-tion,Admitting, Discharge and Transfer (RADT) Functionsin Computer-Based Patient Record SystemsE 1869

18、Guide for Confidentiality, Privacy, Access and DataSecurity Principles for Health Information IncludingComputer-Based Patient RecordsE 1985 Guide for User Authentication and AuthorizationE 2084 Specification for Authentication of Healthcare In-formation Using Digital SignaturesF 1177 Terminology Rel

19、ating to Emergency Medical Ser-vicesF 1288 Guide for Planning for and Response to a MultipleCasualty IncidentF 1629 Guide for Establishing and/or Operating EmergencyMedical Services Management Information Systems2.2 ANSI Standard:X3.172 American National Dictionary for Information Sys-tems 199032.3

20、Institute of Electrical Electronic Engineers Standards:610.12 Standard Glossary of Software Engineering Termi-nology43. Terminology3.1 For definitions of terms used in this specifcation, refer toANSI X3.172 and IEEE 610.123.2 Definitions of Terms Specific to This Standard:3.2.1 emergency conditionch

21、ange(s) in the patientshealth status perceived to require immediate medical attentionto prevent unnecessary death or disability (See also GuideF 1177).3.2.2 emergency department (ED) data setthat set of dataelements collected in the emergency outpatient treatmentfacility prior to admission as an inp

22、atient.3.2.3 emergency encountera single event of health carefor an emergency, such as care at the scene, or at the emergencyoutpatient setting. It concludes when the patient proceeds to thenext phase of care for the emergency.3.2.4 emergency episodea series of encounters relating toan emergency con

23、dition that may lead either to death, fullrecovery, or a clinical steady state.3.2.5 emergency episode documentationthose recordedobservations that describe the care rendered during the periodof an emergency episode, whether brief or extended.3.2.6 other emergency outpatient facilityemergency facil-

24、ity that is not a licensed emergency department connected to anacute care hospital but which provides emergency stabilizationand treatment upon demand. Such facilities may includeclinic/health centers, freestanding ambulatory surgery center,physicians office, etc.3.2.7 pre-hospital EMS data setthat

25、set of data elementscollected at onset and en route prior to arrival at the firsttreatment facility.4. Significance and Use4.1 The Emergency Medical Service System (EMSS) in theUnited States has largely arisen since 1945 and has drawn to agreat degree from the experience gained in military conflicts

26、during and since World War II. The documentation of care,however, has remained largely paper recordbased until re-cently.4.1.1 Beginning in the 1970s both civilian and militaryagencies have closely examined electronic means of storingand managing patient data about emergency medical care.4.1.2 The r

27、eport of the Institute of Medicine on theComputer-Based Patient Record has emphasized the use ofinformation technology in patient care in general and emer-gency care data in particular.4.1.3 During this period ASTM has documented the logicalstructure of the electronic health record in Guide E 1239 a

28、ndPractice E 1384, while Guides F 1288 and F 1629 has definedthe patient care data, to be gathered in the pre-hospital record,and the outcome data, relative to the pre-hospital phase of theemergency, which are collected in the emergency departmentand after inpatient admission.4.1.3.1 Specifications

29、for the logical model are also pre-sented in Practice E 1715.4.2 This practice shows how the data gathered for EMSoperations and management merge smoothly into thecomputer-based patient record, consistent with the recognitionthat these data are part of the primary record of care. Severalstates5have

30、formalized that recognition in state law.4.2.1 This practice does not instruct physicians how tocollect data for patient care.4.2.2 This practice does not indicate what information needsto be collected at the time of patient care.4.3 The task now is to document, using standard conven-tions, the mean

31、s by which this integration occurs in order to setthe stage for the capture and transfer of such emergency caredata using information technology and telecommunications ina standardized way consistent with all other settings of carewhile protecting the privacy and confidentiality of that data.4.3.1 T

32、he electronic health record has the potential to reducehealth care costs by optimizing case management and support-ing effective post ED follow-up.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandard

33、s volume information, refer to the standards Document Summary page onthe ASTM website.3Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036.4Available from Institute of Electrical and Electronics Engineers, Inc. (IEEE),445 Hoes Ln., P.O. Box 1331,

34、 Piscataway, NJ 08854-1331.5State of Washington: Revised Code of Washington 76.168 and WashingtonAdministrative Code 246-976-380.E17440424.3.2 Systematizing the data also enhances its ability to beused consistently, with proper protection, for research into andfor management of EMSS operations withi

35、n the variousjurisdictional boundaries.4.4 The electronic form of the emergency episode documen-tation utilizes the same logical data model as the electronichealth record, but it focuses on data collected during thedifferent phases of the emergency.4.4.1 These data sets do not limit what may be reco

36、rded, orby whom, but they do identify those data considered essential,when they exist. These data sets include all those data recordedto document instances of emergency medical care.4.4.2 Data organized to enhance flexible and efficient man-agement of information.4.4.2.1 Identifications of practitio

37、ners and facilities will becoded, when necessary, to protect confidentiality and to makeprovider data comparable. Names will be included when theyare necessary to support patient care. Privacy and confidenti-ality of patient data should be handled according to GuideE 1869.4.4.2.2 Provider identifica

38、tion numbers will be maintainedon master data files which also include additional informationsuch as specialty, license level, and the like.4.4.2.3 Provider identification numbers recorded in the elec-tronic health record will automatically link to the master datafiles to eliminate the need for dupl

39、icate data entry of referencematerial in the patient record.4.4.2.4 Coding systems for emergency reporting (ICD-9-CM, CPT,6HCPCS,7SNOMED8) will be referenced in themaster data files for Practice E 1384 as appropriate.4.4.2.5 The efficient arrangement of the logical model ofPractice E 1384 permits ou

40、tput to be generated and identifiedto mirror the paper record, such as nurse-specific or physician-specific notes.4.4.2.6 The arrangement of the logical model permits mul-tiple entries of assessment data, using a small group ofvariables, that can then be used to generate output. Forexample, sequence

41、 of diagnoses by date-time.5. Phases of Emergency Medical Care5.1 Patient data are collected during the different phases ofthe emergency by different care providers, the number and typedepend on the severity of the emergency.5.1.1 Fig. 1 presents the different phases of emergency fromonset until fin

42、al disposition, at which point the patient is nolonger the responsibility of emergency care.5.1.2 In some instances, emergency patients are transportedfrom the location of onset to an emergency department andthen later transferred to specialty tertiary care centers to receivetreatment for life-threa

43、tening medical problems.5.1.3 Records completed for the emergency patient at dif-ferent points in time are unique to the type of emergencyresponse and the phase of the emergency.5.1.4 This practice does not include rehabilitation andoutpatient follow-up as part of emergency medical care sincethis in

44、formation is recorded elsewhere in the RHR and is notwithin the scope of this practice.5.2 Documentation of emergency care is more efficient ifthe data are captured at the time of collection so that thisinformation can be incorporated simultaneously into the elec-tronic health record at the time of

45、data entry.5.3 A core of patient identification information (age/date ofbirth, sex/gender, facility identification, times, etc.) is commonto all of the medical records.5.3.1 Other data elements exist that are unique to theemergency event, and still others exist that are unique to aspecific care site

46、.5.3.2 Although many different records may be completedfor a single emergency patient, not all of the data collected areincorporated into the electronic health record.5.3.2.1 Except for times (see 6.14.4 and 6.14.14), adminis-trative data which are useful for ambulance service manage-ment informatio

47、n, such as the use of lights and sirens andmileage, the EMS agencys response number, the type of EMSvehicle, and environmental factors affecting EMS care, havebeen excluded from the electronic health record, which focuseson the patient.5.4 The electronic health record has the potential to improvedat

48、a quality as follows.5.4.1 Time and date entries will not be subject to theidiosyncrasies of the clock at hand, or the memory of theperson entering the data but may be automatically recorded bythe computer; however, when data are entered retrospectively,the system should allow a manual override to r

49、ecord actualtime.5.4.2 Direct data entry, by voice, dictation, touch, etc., bythe care provider will eliminate the need to interpret the careproviders handwriting.5.5 Each segment of emergency care is cumulative, thoughnot necessarily sequential, to the prior documentation in thecomputerbased patient record. Data entered also may updateprevious documentation.5.6 The EMS data set is and will continue to be a subset ofPractice E 1384 and Specification E 1633; it will continue to beincluded in Guide F 1629, EMS-MIS global lists of elements.5.6.1 Each encounter contains con