Making Standards Work for You - Content Vocabulary for Computer-based Patient Records

Sep 28, 2026

Uploaded by kopisore

The article explains how ASTM standards advance computer-based patient records (CPR) in the 1990s, emphasizing ASTM E1384 as a central standard for characterizing clinical content and enabling consistent information system design. It summarizes updates associated with the 1996 changes, outlines practical directions for applying and using the standard, and describes the added value for health informatics and health information management. It also provides background on ASTM and AHIMA collaboration and links CPR vocabulary to related code systems and companion standards.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Background

ASTM and AHIMA collaboration

Selected ASTM subcommittees and ongoing work

ASTM E1384 Standard Guide for CPR Content and Structure

Standard development history and editions

Core framework and evolving content definition

Data representation, coded values, and linkages

Five purposes and scope

Making Standards Work for You: Content Vocabulary for Computer-based Patient Records Save to myBoK by Gretchen Murphy, MEd, RRA Standards mark the progress of and contribute to strategies for achieving computer-based patient records (CPR) in the 1990s. The ASTM E1384 Standard Guide for Content and Structure of the Computer-based Patient Record illustrates this fact. Not only is this standard central to characterizing the clinical content of the patient care record, but it promotes consistent processes for designing the information systems that will serve as CPR components. This article provides updates on the l996 changes in the standard, directions on its application and use, and a look at the impact and value added to health informatics and the health information management profession. Background Organized in 1898, the American Society for Testing Materials (ASTM) has grown to one of the largest voluntary standards development systems in the world. ASTM publishes more than 9800 standards each year including standards for health informatics through Committee E31. These standards are sold throughout the world. Through ongoing support and the active participation of AHIMA volunteers and staff, significant progress has been made in leadership and collaboration with industry colleagues involved in standards activities. Today, key E31 health informatics subcommittees are chaired by AHIMA representatives, and their membership includes a number of HIM professionals. In fact, a focus on computer-based patient record developments is shared among several subcommittees within ASTM. Table 1 depicts the collaborative work in progress. | Table 1
How Selected ASTM Subcommittees Contribute to Healthcare Informatics | | | | --- | --- | --- | | | Existing Standards | Work in Progress | | Models
Framework | E1715 Practice for an Object Model for Work here provides overall models to Registration/ Admission/Discharge/Transfer which the CPR conforms (RADT) Functions in CPR systems Subcommittee E31.19 | Work here provides overall models to which the CPR conforms | | Healthcare Terminology
Infrastructure | Subcommittee E31.01
Subcommittee E31.21 | Work here will provide guidance to terminology use in standards
Work here focuses on networks | | CPR Content Definition
Evolving Repository | E1239 Guide for Description of RADT Systems Subcommittee E31.19 | This standard defines initial identifying and demographic data related to CPRs | [https://bokold.ahima.org/doc?oid=58446](https://bokold.ahima.org/doc?oid=58446) 1/7 11/21/24 , 12:59 PM Making Standards Work for You: Content Vocabulary for Computer-based Patient Records | | E1384 Standard Guide for Content and Structure of the CPR
Subcommittee E31.19
E1633 Coded Values for Data in Automated Primary Record of Care (CPR) systems Subcommittee E31.19
E1744 Standard Guide for a View of Emergency Medical Care in the Computerized Patient Record Subcommittee E31.12
Subcommittee E31.22 | Work here will add to the minimum content view in E1384 by continually expanding possible vocabulary and aligning it with companion standards (HL7 and others)
Work here builds ongoing master tables and pointers to code systems for CPR content data specified in E1384
This standard depicts a specified view for the CPR and builds on common vocabulary from E1384
Creating standards for medical transcription | | --- | --- | --- | | Key Functions of CPR Systems:
Critical Attributes
Universal Features | E1762 Guide for Electronic Authentication of Health Care Information
Subcommittee E31.20
Subcommittee E31.17 | Developing both principles and technical functions
Access , privacy, and confidentiality are in the balloting process | | System Properties
Functional Requirements | E1769 Guide to Properties of Electronic Health Records and Record Systems Subcommittee E31.12 E1714 Guide for Properties of Universal Health Identifier
Subcommittee E31.12
E1239

FAQs

What role does ASTM E1384 play in computer-based patient records?

ASTM E1384 is described as a vocabulary content standard central to characterizing clinical content and promoting consistent processes for designing CPR-related information systems.

What kind of updates are associated with the 1996 edition mentioned in the article?

The article states that the 1996 edition expands the definition of purposes and principles and supports an evolving approach to content definition in CPR vocabulary.

How does the article describe the relationship between CPR vocabulary and other standards or code systems?

It explains that data representation through coded values and master tables links the vocabulary directly to established code systems and to other standards, including companion standards such as HL7 and related vocabulary views.

Sep 28, 2026

Uploaded by kopisore