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E2184-02 Standard Specification for Healthcare Document Formats (Withdrawn 2011)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Withdrawn Standard: Standard Specification for Healthcare Document Formats (Withdrawn 2011)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