【国外标准】 Standard Specification for Coded Values Used in the Electronic Health Record (Withdrawn 2017)

4.1 Purpose—The approval of Guide E1384, concerned with the structure and content of the computer-based patient record, now includes a formal indexing of data elements and a cataloging of the minimal essential value set for these elements. Indexing of these data elements with a unique identifier keyed to its position in the logical structure of Appendix X1 of Guide E1384 now provides a means of cataloging the value sets representing each data element (see Guide E1384). Guide E1239 describes conventions for representing many of the data values for data elements that are included in the more comprehensive listing in Guide E1384. A comprehensive listing of all of the value sets associated with Guide E1384 has not yet been assembled. This specification begins to catalog the representation conventions for a number of these elements and in particular to list the coded values. It is important that this catalog consider the traditionally assigned representations for each of these elements, and it must resolve differences in a manner that introduces systematics and consistency into the representation. The catalog must establish both a global framework consistent with international standardization and with long-term growth, while at the same time maximizing familiar or traditional representations. This standard has been developed with input from many organizations, including government agencies and other standards bodies and professional associations, and as a result of the effort to achieve consistency and comprehensiveness among the data dealt with by various standards efforts.4.2 General Values—Early in the coordination of healthcare information standards an informal body, the Healthcare Information Standards Coordinating Committee (HISCC), identified certain common data element types and agreed upon conventions for representing these data element types in a standard manner. This set the stage for the development of the value sets for the CODED VALUE data type. The status of the standard noncoded data types, and their representations, agreed upon by the HISCC are:4.2.1 Person Names—Guide E1239, Practice E1715, Practice E1744, and HL-7 use the same representation for American and European forms.4.2.2 Addresses—Common format in Guide E1239, Practice E1715, and Practice E1744.4.2.3 Telephone Numbers—Guide E1239 currently uses the same representation with area code enclosed in parentheses and country code preceding the parentheses.4.2.4 Dates—Date and time represented as ANS X3.51-1986/ISO 8601-1988 with years in four digits; time not separated from date by “T” as permitted by ISO 8601.4.2.5 Numbers—Numbers are represented either as integers or fixed point numbers; exponential notation not presently accepted in Guide E1239 or HL-7. Units of Measure by ISO 2955-1983 or ANS X3.50-86.4.2.6 Strings—7-bit ASCII characters; multilingual character sets not yet defined.5AbstractThis specification covers all paper and automated systems related to the identification of the lexicons to be used for the data elements intended to unify the representations for: (1) primary record of care data elements; (2) the data elements identified in other standard statistical data sets; (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose; and (5) in data derived from these elements in order that data recorded in the course of patient care be exchangeable and be the source of accurate statistical and resource management data.1.1 This specification covers the identification of the lexicons to be used for the data elements identified in Appendix X1 of Guide E1384. It is intended to unify the representations for: (1) primary record of care data elements, (2) the data elements identified in other standard statistical data sets, (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose, and (5) in data derived from these elements in order that data recorded in the course of patient care be exchangeable and be the source of accurate statistical and resource management data. This specification is applicable to all paper and automated systems.