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ASTM-E2184:2002 Edition

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E2184-02 Standard Specification for Healthcare Document Formats (Withdrawn 2011)

Published By Publication Date Number of Pages
ASTM 2002 10
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ASTM E2184-02

Withdrawn Standard: Standard Specification for Healthcare Document Formats (Withdrawn 2011)

ASTM E2184

Scope

1.1 This specification addresses requirements for the headings, arrangement, and appearance of sections and subsections when used within an individual’s healthcare documents. This specification will facilitate identification and retrieval of health information in a manner that will enhance the quality and efficiency of health services. Use of this specification in conjunction with XML DTDs (extensible markup language document type definitions) and the EHR (electronic health records) would further enhance efficiency in time and cost. This specification applies across multiple healthcare settings in which healthcare documents are generated, such as hospitals, clinics, skilled nursing facilities, ambulatory care facilities, outpatient surgery centers, and private healthcare providers’ offices.

1.2 This specification addresses the headings, arrangement, and appearance of sections and subsections of healthcare documents, however generated (dictation/transcription, speech recognition, touch-screen entry, and so forth) and whether displayed electronically or on paper. It does not address the titles of healthcare documents or the content of sections and subsections.

1.2.1 The author of a healthcare document may choose to summarize subsection information within a general section rather than creating subsections.

1.3 The format and content of patient-identifying data are addressed in Guide E 1384.

1.4 Issues of confidentiality and security are addressed in Guide E 1869, Guide E 1902, Guide E 1762, Guide E 1985, Guide E 1986, Guide E 1987, Guide E 1988, Specification E 2084, Guide E 2085, and Guide E 2086, as well as in Specification E 2147.

1.5 Issues of XML DTDs are addressed in Specification E 2182 and Guide E 2183.

Keywords

appearance; arrangement; format; headings; healthcare document; sections; subsections

ICS Code

ICS Number Code 35.240.80 (IT applications in health care technology)

DOI: 10.1520/E2184-02

PDF Catalog

PDF Pages PDF Title
1 Scope
Referenced Documents
Terminology
2 Significance and Use
Specifications
3 Keywords
A1. HEADINGS FOR SECTIONS AND SUBSECTIONS OF HISTORY AND PHYSICAL EXAMINATION REPORTS AND RELATED HEALTHCARE DOCUMENTS
A1.1 Headings for sections and subsections
A1.2 Patient-identifying Data
A1.3 Section Heading: CHIEF COMPLAINT(S)
A1.4 Section Heading: REASON FOR ENCOUNTER
A1.5 Section Heading: HISTORY OF PRESENT ILLNESS
A1.6 Section Heading PAST HISTORY
A1.7 Section Heading: ALLERGIES
4 A1.8 Section Heading: CURRENT MEDICATIONS
A1.9 Section Heading: REVIEW OF SYSTEMS
A1.10 Section Heading: PHYSICAL EXAMINATION
5 A1.12 Section Heading: DIAGNOSTIC STUDIES
A1.13 Section Heading: FINDINGS
A1.14 Section Heading: DIAGNOSIS or DIAGNOSES
A1.15 Section Heading: PROGNOSIS
A1.16 Section Heading: PLAN
A1.17 Section Heading: ORDERS
A1.18 Section Heading: COURSE
A1.19 Section Heading: PROCEDURES/INTERVENTIONS
A1.20 Section Heading: PRACTITIONER
A1.21 Section Heading: ADVANCE DIRECTIVES
6 A1.22 Accountability
A1.23 Distribution
A1.24 Amendments
X1. HEADINGS EXAMPLE
X1.1
7 X2. TEMPLATE FOR SECTIONS AND SUBSECTIONS
X2.1
10 REFERENCES
ASTM-E2184
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