Designation:E1744−04(Reapproved2010)AnAmericanNationalStandardStandardPracticeforViewofEmergencyMedicalCareintheElectronicHealthRecord1ThisstandardisissuedunderthefixeddesignationE1744;thenumberimmediatelyfollowingthedesignationindicatestheyearoforiginaladoptionor,inthecaseofrevision,theyearoflastrevision.Anumberinparenthesesindicatestheyearoflastreapproval.Asuperscriptepsilon(´)indicatesaneditorialchangesincethelastrevisionorreapproval.1.Scope1.1Thispracticecoverstheidentificationoftheinformationthatisnecessarytodocumentemergencymedicalcareinanelectronic,paperlesspatientrecordsystemthatisdesignedtoimproveefficiencyandcost-effectiveness.1.2Thispracticeisaviewofthedataelementstodocumentthetypesofemergencymedicalinformationthatshouldbeincludedintheelectronichealthrecord.1.2.1Thepatient’ssummaryrecordandderiveddatasetswillbedescribedseparatelyfromthispractice.1.2.2Asaviewoftheelectronichealthrecord,theinfor-mationpresentedwillconformtothestructuredefinedinotherASTMstandardsfortheelectronichealthrecord.1.3ThispracticeisintendedtoamplifyGuidesE1239andF1629andtheformalismsdescribedinPracticesE1384andE1715.1.3.1ThispracticedetailstheuseofdataelementsalreadyestablishedinthesestandardsandothernationalguidelinesforuseduringdocumentationofemergencycareinthefieldorinatreatmentfacilityandplacestheminthecontextoftheobjectmodelsforhealthcareinPracticeE1384thatwillbethevehicleforcommunicationstandardsforhealthcaredata.1.3.1.1Thedataelementsandtheattributesreferredtointhispracticearebasedonnationalguidelineswheneveravail-able.1.3.1.2TheEMSdefinitionsarebasedonthosegeneratedfromthepreviousEMSconsensusconferencesponsoredbyNHTSAandfromASTMtaskgroupF30.03.03onEMSManagementInformationSystems.1.3.1.3TheEmergencyDepartment(ED)definitionsarebasedontheDataElementsforEmergencyDepartmentSys-tems(DEEDS)distributedbytheCentersforDiseaseControlinJune1997.1.3.1.4ThehospitaldischargedefinitionsarebasedonrecommendationsfromtheCentersforMedicareandMedicaidServices(CMS)forMedicareandMedicaidpaym...
