1、Designation:E 1284 97An American National StandardStandard Guide forConstruction of a Clinical Nomenclature for Support ofElectronic Health Records1This standard is issued under the fixed designation E 1284;the number immediately following the designation indicates the year oforiginal adoption or,in
2、 the case of 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.INTRODUCTIONThe first ASTM guide for the construction of a new clinical nomenclature was published
3、in 1989(Guide E 1284).It reflected the knowledge and insight of that time.Subsequently,substantial progresshas taken place in this subject area,mostly as part of the efforts toward the development of electronichealthcare records.These efforts have indicated that a clinical nomenclature is a sine qua
4、 non(tool),the heart of the electronic patient records generation,and the experience gained has provided somenew and some modified criteria for such a clinical nomenclature.These recent developments haveprompted Subcommittee E31.12 to revise Guide E 1284 and to include the new knowledge andinformati
5、on that has accumulated during the last few years.1.Scope1.1 This guide covers the clinical terms used in everydayclinical communication.1.2 This guide does not cover terminology listings preparedfor other purposes such as those for reimbursement,literatureretrieval or scientific reference encoding,
6、because the criteriafor these types of term listings are significantly different fromthose to be observed when a nomenclature is constructed forthe support of clinical informatics activities.1.3 This guide is intended to outline the nosologic conceptsfor a clinical nomenclature that is designed to s
7、upport elec-tronic healthcare records.1.4 The purpose of this guide is to describe the desiderata(needed requirement)for a nomenclature that is dedicated toclinical use and can serve as a way for maintaining nationwidecompatibility among electronic healthcare records generated inthe United States.1.
8、5 This standard does not purport to address all of thesafety concerns,if any,associated with its use.It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory limitations prior to use.2.Referenced Documen
9、ts2.1 ASTM Standards:E 1384 Guide for Description for Content and Structure ofan Automated Primary Record of Care2E 1769 Guide for Properties of Electronic Health Recordsand Record Systems22.2ISO Standards:ISO 5218Information Interchange3ISO 2955 Information Processing3ISO 8072 Network Standards3ISO
10、 8601Data Elements and Interchange Formats3ISO 8859 Information Processing3ISO 5218 IS Representation of the Human Sexes3ISO IS 704 Principles and Methods of Terminology3ISO DIS 860 International Harmonization of Concepts andTerms3ISO DIS 10871 Terminology Work-Vocabulary-Part I:Theory and Applicati
11、on3ISO DIS 10872 Terminology Work-Vocabulary-Part II:Computational Aids in Terminology3ISO DIS 1951 Lexigraphic Symbols and TypographicalConventions for Use in Terminography3ISO TR 9789 Information System TechnologyGuidelinesfor the Organization and Representation of Data Elementsfor Data Interchang
12、eCoding Methods and Principles3ISO IS 1024 International Terminology StandardsPreparation and Layout3ISO DIS 12616 Translation-Oriented Terminology3ISO DIS 12200TerminologyComputer Applications1This guide is under the jurisdiction of ASTM Committee E-31 on HealthcareInformatics and is the direct res
13、ponsibility of Subcommittee E31.01 on ControlledHealth Vocabularies for Healthcare Informatics.Current edition approved Aug.10,1997.Published March 1998.Originallypublished as E 128489.Last previous edition E 128489.2Annual Book of ASTM Standards,Vol 14.01.3Available from American National Standards
14、 Institute,11 W.42nd St.,13thFloor,New York,NY 10036.1Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959,United States.Machine Readable Terminology Interchange Format3ISO DIS 12620 TerminologyComputer ApplicationsData Categories32.3ANSI Standards:ANSI ASCX
15、12 Version 3,Release 33ANSI X3.30 Representation for Calendar Date and Ordi-nary Date3ANSI X3.43 Information Systems Representation of LocalTime of Day for Information Exchange3ANSI X3.51 Representations of Universal Time,LocalTime Differentials,and United States Time Zone Refer-ences for Informatio
16、n Interchange32.4Other Standards:HL7:Health Level Seven Version 2.24ACR/NEMA:DICOM Version 3.0CEN ENV 12262Model of Semantics3.Terminology3.1 Definitions of Terms Specific to This Standard:Termdefinitions in this section are limited to the characterization ofthe meaning of terms in context of this guide,namely,themeaning for construction of a clinical nomenclature for thesupport of automated creation of electronic health records.3.1.1 attribute selection for hierarchical classificationchoice of
