Designation:E2184–02AnAmericanNationalStandardStandardSpecificationforHealthcareDocumentFormats1ThisstandardisissuedunderthefixeddesignationE2184;thenumberimmediatelyfollowingthedesignationindicatestheyearoforiginaladoptionor,inthecaseofrevision,theyearoflastrevision.Anumberinparenthesesindicatestheyearoflastreapproval.Asuperscriptepsilon(e)indicatesaneditorialchangesincethelastrevisionorreapproval.1.Scope1.1Thisspecificationaddressesrequirementsforthehead-ings,arrangement,andappearanceofsectionsandsubsectionswhenusedwithinanindividual’shealthcaredocuments.Thisspecificationwillfacilitateidentificationandretrievalofhealthinformationinamannerthatwillenhancethequalityandefficiencyofhealthservices.UseofthisspecificationinconjunctionwithXMLDTDs(extensiblemarkuplanguagedocumenttypedefinitions)andtheEHR(electronichealthrecords)wouldfurtherenhanceefficiencyintimeandcost.Thisspecificationappliesacrossmultiplehealthcaresettingsinwhichhealthcaredocumentsaregenerated,suchashospitals,clinics,skillednursingfacilities,ambulatorycarefacilities,outpatientsurgerycenters,andprivatehealthcareproviders’offices.1.2Thisspecificationaddressestheheadings,arrangement,andappearanceofsectionsandsubsectionsofhealthcaredocuments,howevergenerated(dictation/transcription,speechrecognition,touch-screenentry,andsoforth)andwhetherdisplayedelectronicallyoronpaper.Itdoesnotaddressthetitlesofhealthcaredocumentsorthecontentofsectionsandsubsections.1.2.1Theauthorofahealthcaredocumentmaychoosetosummarizesubsectioninformationwithinageneralsectionratherthancreatingsubsections.1.3Theformatandcontentofpatient-identifyingdataareaddressedinGuideE1384.1.4IssuesofconfidentialityandsecurityareaddressedinGuideE1869,GuideE1902,GuideE1762,GuideE1985,GuideE1986,GuideE1987,GuideE1988,SpecificationE2084,GuideE2085,andGuideE2086,aswellasinSpecificationE2147.1.5IssuesofXMLDTDsareaddressedinSpecificationE2182andGuideE2183.2.ReferencedDocuments2.1ASTMStandards:E1384GuideforContentandStructureoftheElectronicHealthRecord...
