ASTM International

Standard Practice for View of Emergency Medical Care in the Electronic Health Record
 N E1744

Annotation

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.

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.

The patient's summary record and derived data sets will be described separately from this practice.

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.

This practice is intended to amplify Guides E1239 and F1629 and the formalisms described in Practices E1384 and E1715.

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.

The data elements and the attributes referred to in this practice are based on national guidelines whenever available.

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.

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.