Inventory of Health Care Information Standards. ASTM E1384-96 Standard Guide for Content and Structure of the Computer-Based Patient Record


Contact: Manager - Committee E31, ASTM

100 Barr Harbor Drive

West Conshohocken, PA 19373

Ph: 610-832-9500

Fax: 610-832-9666

Standard Description

This standard guide is intended to provide the framework vocabulary for the computer-based patient record content. It proposes a minimum essential content drawn from a developing annex of dictionary elements.

Elements are populated using master tables which range from standard code systems to reference tables harmonized with HL-7 Version 2.2. It calls for unique data views specified

for clinical settings. The standard contains an annex of dictionary items intended as a reference standard for designers and developers.

Functions: Implementation Independent Content Organization

Master Tables

Data Views

User Environment: Administrative And Clinical Users

Software Developers - Data Base Design

Educators - Health Informatics

Systems Environment: Does Not Specify System Environment

Evolving Standard - Ongoing Development

Most Complete CPR Content Standard


There are no other standards that address the overall content vocabulary for computer-based patient records. This standard offers an initial data model intended for application in all healthcare settings. It currently serves as a reference model for vendors and institutions working to build data base content for CPRs.

Readiness of the Standard

A) This standard is a guideline that addresses policy and design. Since it offers an overall data model, users would incorporate the elements of the standard that apply to their situation. For example, requests for this standard come from designers working on the data content of the CPR. The proposed content is being used as a base data model and for data definitions.

B)This standard does not require a separate implementation guide. It should be used in conjunction with the Standard Specification for Coded Values for the Computer-Based Patient Record E1633 to achieve more specificity. Vocabulary data elements are defined in E1384, which include limited code values and pointers to E1633 for the specific master tables and code systems and values needed for the data elements. Code sets are assumed, referenced in E1633 for data elements; and harmonized with code sets in HL-7 where feasible.

C)How can the standard be obtained? ASTM standards are available through the ASTM Customer Service Department by calling 610-832-9585. Standards can also be ordered through the ASTM Web Site at www.

The standard is fully usable now as a reference guide for designers/developers of Computer-Based Patient Records.


Milestones identified are additional content, harmonization with companion standards and joint development work on new vocabulary. The most recent ballot was in l996. Proposed revisions are already in development and updates will be balloted in l997.

Indicator Of Market Acceptance

A)If the standard is a guideline, how many copies have been requested and distributed? Approximately 2300 copies of the E31 standards have been distributed.

B)If the standard is an implementable standard, how many vendors, healthcare organizations, and/or government agencies are using it?

This type of information is difficult to obtain for the E31 standards. It is indicated where available under the document specific information to follow.

This standard is included in the ASTM l996 Book of standards made available to people who join ASTM. Currently, the membership of E31 Committee on Healthcare Informatics is over 300. Actual numbers of interested individuals who have requested this standard far exceeds the membership.

The Veterans Administration reports using this as a reference standard.

Other indicators of market acceptance include users who are currently involved in developing CPR applications within individual hospitals and hospital consortiums; vendors who are working on CPR data repository models; and CPR project planners who are in the process of defining content standards for their enterprise.

This standard is also included in a l996 publication that has been adopted by all Health Information Administration programs in the United States.

Level of Specificity

This standard is a guide. It calls for standard content expressed in a uniform manner. It does not provide data dictionary specificity. It identifies the common information framework that is part of patient records in multiple settings.

Relationship With Other Standards

As indicated, this standard depends on ASTM E1633 for specified coded values; uses some HL-7 data elements and a limited number of master tables. Ongoing analysis is performed to continue work on harmonizing elements with collaborative work, e.g. the Minimum Data Set from the National Committee on Vital and Health Statistics. Harmonization with message standards are proposed for revisions where possible. Functionality will be strengthened by coordination. Conditions assumed for coordination to be effective include joint work initiatives among standards developers and representatives from the user community who currently use this standard.

E1384 can be obtained from ASTM at:

100 Barr Harbor Drive, West Conshohocken, PA 19428

(610) 832-9500 Web Site:

Category/Classification Of The Standard

Health Claim Attachments