An American National Standard

Designation: E 1284 – 97

Standard Guide for

Construction of a Clinical Nomenclature for Support of
Electronic Health Records1
This standard is issued under the fixed designation E 1284; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.

INTRODUCTION

The first ASTM guide for the construction of a new clinical nomenclature was published in 1989
(Guide E 1284). It reflected the knowledge and insight of that time. Subsequently, substantial progress
has taken place in this subject area, mostly as part of the efforts toward the development of electronic
healthcare records. These efforts have indicated that a clinical nomenclature is a sine qua non (tool),
the heart of the electronic patient records generation, and the experience gained has provided some
new and some modified criteria for such a clinical nomenclature. These recent developments have
prompted Subcommittee E31.12 to revise Guide E 1284 and to include the new knowledge and
information that has accumulated during the last few years.

1. Scope E 1384 Guide for Description for Content and Structure of

1.1 This guide covers the clinical terms used in everyday an Automated Primary Record of Care2
clinical communication. E 1769 Guide for Properties of Electronic Health Records
1.2 This guide does not cover terminology listings prepared and Record Systems2
for other purposes such as those for reimbursement, literature 2.2 ISO Standards:
retrieval or scientific reference encoding, because the criteria ISO 5218 Information Interchange3
for these types of term listings are significantly different from ISO 2955 Information Processing3
those to be observed when a nomenclature is constructed for ISO 8072 Network Standards3
the support of clinical informatics activities. ISO 8601 Data Elements and Interchange Formats3
1.3 This guide is intended to outline the nosologic concepts ISO 8859 Information Processing3
for a clinical nomenclature that is designed to support elec- ISO 5218 IS Representation of the Human Sexes3
tronic healthcare records. ISO IS 704 Principles and Methods of Terminology3
1.4 The purpose of this guide is to describe the desiderata ISO DIS 860 International Harmonization of Concepts and
(needed requirement) for a nomenclature that is dedicated to Terms3
clinical use and can serve as a way for maintaining nationwide ISO DIS 1087–1 Terminology Work-Vocabulary-Part I:
compatibility among electronic healthcare records generated in Theory and Application3
the United States. ISO DIS 1087–2 Terminology Work-Vocabulary-Part II:
1.5 This standard does not purport to address all of the Computational Aids in Terminology3
safety concerns, if any, associated with its use. It is the ISO DIS 1951 Lexigraphic Symbols and Typographical
responsibility of the user of this standard to establish appro- Conventions for Use in Terminography3
priate safety and health practices and determine the applica- ISO TR 9789 Information System Technology—Guidelines
bility of regulatory limitations prior to use. for the Organization and Representation of Data Elements
for Data Interchange—Coding Methods and Principles3
2. Referenced Documents ISO IS 1024 International Terminology Standards—
2.1 ASTM Standards: Preparation and Layout3
ISO DIS 12616 Translation-Oriented Terminology3
ISO DIS 12200 Terminology—Computer Applications—
1
This guide is under the jurisdiction of ASTM Committee E-31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.01 on Controlled
2
Health Vocabularies for Healthcare Informatics. Annual Book of ASTM Standards, Vol 14.01.
3
Current edition approved Aug. 10, 1997. Published March 1998. Originally Available from American National Standards Institute, 11 W. 42nd St., 13th
published as E 1284–89. Last previous edition E 1284–89. Floor, New York, NY 10036.

Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.

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Machine Readable Terminology Interchange Format3 level. The “best” attribute chosen by the architects of the
ISO DIS 12620 Terminology—Computer Applications— nomenclature should be critically evaluated in terms of the
Data Categories3 current view of clinical practice with regard to that particular
2.3 ANSI Standards: class term partitioning (textbooks, monographs, etc.), and the
ANSI ASCX12 Version 3, Release 33 impact of a particular class term partitioning upon the retrieval
ANSI X3.30 Representation for Calendar Date and Ordi- of that term or related terms in actual usage.
nary Date3 3.1.6 concept—a summarizing abstract idea derived from a
ANSI X3.43 Information Systems Representation of Local generalizing process, following an abstracting mental process.
Time of Day for Information Exchange3 Concept is a general notion to represent a class of objects.
ANSI X3.51 Representations of Universal Time, Local 3.1.6.1 clinical concept—a mental image generated and
Time Differentials, and United States Time Zone Refer- used within the domain of clinical activities, based on the
ences for Information Interchange3 characteristics of a class of real-world instances, including the
2.4 Other Standards: features typically associated with or suggested by that image.
HL7: Health Level Seven Version 2.24 3.1.7 health record—the collection of data and information
ACR/NEMA: DICOM Version 3.0 gathered, or generated, to document (clinical care rendered to
CEN ENV 12262 Model of Semantics an individual) the conditions of an individual and any health
care planned, ordered, or rendered.
3. Terminology
3.1.7.1 electronic health record—a comprehensive, struc-
3.1 Definitions of Terms Specific to This Standard: Term tured set of clinical, demographic environmental, social, and
definitions in this section are limited to the characterization of financial data and information, in electronic form, documenting
the meaning of terms in context of this guide, namely, the the health care planned, ordered, or rendered related to a single
meaning for construction of a clinical nomenclature for the individual. The electronic health record may include health
support of automated creation of electronic health records. related information from non-clinical sources that may not
3.1.1 attribute selection for hierarchical classification— fully conform to the standardized clinical nomenclature. Even
choice of a characterizing feature of a class of concepts that so, when possible, such information should be interpreted and
allows partitioning, as defined by the architects of the classi- classified, according to the paradigm of the clinical nomencla-
fication system. (Three most successful classification systems ture. This will allow handling such material effectively.
used a single attribute: botany used binomial attribute, biology 3.1.8 hierarchical classified system—a special subset of
related classification to evolution, chemistry utilized the atomic classified systems with stepwise ranking of the concepts where
weight.) subordinated lower level concepts are the result of a partition-
3.1.2 class term—a term that encompasses terms that are in ing process, based on a preselected and clearly stated at-
one sense similar but in some another sense heterogeneous, tribute(s).
dissimilar. A class term is clinically meaningfully partitioned, 3.1.9 lexical meaning—the definition of the meaning, a
when this partitioning results in subclasses with increased word or phrase generally, out of context, as listed in appropri-
similarity among the members of each subclass. ate lexicons, such as medical dictionaries.
3.1.3 class term partitioning—the act of separating a class
3.1.10 nomenclature—comprehensive systematized termi-
concepts into subclasses, where the created subclasses include
nology where the preferred terms are ordered into a classified
all members of the partitioned class term.
system based on their meaning and where semantic kinships
3.1.4 classified system—systematic arrangement of con-
are held together.
cepts into categories according to preset explicit criteria,
3.1.11 nosology—the science and technology of naming and
following a chosen nosologic scheme, such a hierarchical or
classifying clinical concepts, such as anatomic terms, bio-
matrix arrangement.
chemical and physiologic terms, symptoms, signs, clinical
3.1.5 compound hierarchy—a stepwise hierarchical ar-
problems and diagnoses, terms of etiology and therapy, nurs-
rangement where more than one attribute is used for partition-
ing, and others used by healthcare team members. Nosology is
ing. The most appropriate attribute to guide the act of parti-
domain specific.
tioning is chosen by the architects of the nomenclature.
3.1.5.1 Discussion—Design of a particular equally good 3.1.11.1 nosologic sheme—a currently accepted and pre-
hierarchy tree is not to be viewed as necessarily the only vailing thinking about organization of clinical concepts based
acceptable partitioning scheme. An alternative is the matrix on accepted classification theories (probabilistic reasoning,
design. Furthermore, partitioning of some class terms is fuzzy set theory, etc.).
controversial. For example, the concept anemia, an obvious 3.1.12 single-key hierarchy—also called directly hierarchy,
class term, may be partitioned on the basis of the size of the red is a stepwise hierarchical arrangement of concepts using the
cells (nomocytic, macrocytic and microcytic anemias), by the same single attribute (the key) for partitioning throughout the
use of erythrokinetic differences (increased loss or insufficient nomenclature.
production of red cells), or on the basis of the reticulocyte 3.1.12.1 Discussion—Theoretically, all clinical terms
should be classifiable into a single-key hierarchy where all
class terms and subclass terms are based on a single key such
4
Available from Health Level 7, 3300 Washtenaw Ave., Suite 227, Ann Arbor, as etiology, or outcome, or some other preselected key at-
MI 48108. tribute. Our present knowledge does not allow the creation of

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such a pure direct hierarchy. For example, if etiology would be 3.1.14.4 preferred term—the term that has been formally
chosen as sole-key attribute, terms with multiple etiologies or chosen by the architects of the nomenclature as the most
considered idiopathic would create difficulties. appropriate representation of a particular concept. Generally,
3.1.13 tangled hierarchy—a particular subset of hierarchi- descriptive terms are preferred over eponymic terms.
cal arrangements which permits the occurrence of certain terms 3.1.14.5 synonymous term—also called admitted term,
in multiple but interlinked positions. means a term with identical meaning and usage as the preferred
3.1.13.1 Discussion—Organ system-based systematization term, and deemed interchangeable with the preferred term.
is traditional and deep-seated in clinical medicine, but this 3.1.14.6 terminal term—also called end term, is a term that
widely used organization may occasionally fail, for example, cannot be further partitioned in order to gain increased simi-
with the classification of the ovaries which belong both to the larity among instances. During a particular class term parti-
family of endocrine glands and to the female reproductive tioning, attention must be focused upon the quality of retrieval
organs. of subclass terms in actual usage. Prudent selection of the key
3.1.14 term—a word or phrase having a limiting and defi- attribute for the partitioning of each class term should aim at
nite meaning in a particular branch of science or art. Linguis- the clinically most useful key, and this may be a recursive
tically, a term is a word or phrase representing a concept. process, driven by the benefits gained by alternative partition-
Semantically, a term is a word or phrase with a defined lexical ings. It is also an option to include all the several currently
meaning. Clinically, a term is a word or phrase used in accepted partitions of a class term, such as in the case of
professional clinical communication that has a generally ac- anemia, and let the user select the partitioning of choice.
cepted valid clinical meaning. 3.1.15 terminology—an aggregate of terms representing
3.1.14.1 deprecated term—a word or phrase synonymous or various concepts of a particular subject area.
near-synonymous with the preferred term but disapproved by 3.1.15.1 clinical terminology—an aggregate of terms repre-
the architects of the nomenclature, deemed to be obsolete, senting currently accepted clinical concepts.
misnomered, incorrect, ambiguous, or potentially offensive. 3.1.15.2 Discussion—A clinical term is the linguistic repre-
3.1.14.2 descriptive term—a word or phrase referring to a sentation of a clinical concept, or a healthcare-related concept,
characteristic attribute of the concept represented, such as such as “cerebral concussion” or “activities of daily living,”
regional enteritis. and includes all healthcare-related terms. Bioclinical terminol-
3.1.14.3 eponymic term—a word or phrase linked to a ogy is larger in scope, also including many basic science terms
particular person’s name, such as Crohn’s disease. such as “electron donor” or “genetic transcription.” Generally,

NOTE 1—The field of nosology is still in an evolutionary phase, and other classification schemes may be equally effective.
FIG. 1 An Optional Classification Scheme for Clinical Terms

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 E 1284 – 97
such bioclinical terms are clinically pertinent, but infrequently Terminology (CPT), SNOMED III and various specialty ter-
used in clinical communication. minologies such as the Diagnostic and Statistical Manuals of
Mental Disorders (DSM-IV) or the various nursing vocabular-
4. Criteria for a Clinical Nomenclature to Support ies.
Generation of Electronic Health Records 4.1.8 Coded—The code should uniquely and permanently
4.1 The following are some essential criteria: represent the corresponding term. This code scheme should not
4.1.1 Comprehensive— The nomenclature supporting elec- carry information about the term. In addition, a meaningful
tronic health records shall list all the clinical terms used by all code may be attached, based on the clinical meaning and the
members of the healthcare team involved in record writing. nature of the parental terms; such a code may be valuable in
Moreover, the nomenclature shall list all preferred terms, keeping semantic kinships together, which may be particularly
synonyms, near-synonyms and vernacular expressions that helpful for flexible retrieval.
may be encountered in a health record. 4.1.9 Clinical Communication Oriented—The nomencla-
4.1.2 Source and Context Sensitive—Ambiguous clinical ture should not only list the canonical (pure concept-based)
terms must be resolved by appropriate codes. For example, clinical terms, but also phrases, abbreviations, idioms, and
“dyspnea” may be a symptom or a sign. After interpreting the other expressions that may be present in a clinical record.
source or context, or both, the nomenclature must be able to 4.1.10 Compatible—The nomenclature should maintain
differentiate such ambiguities. compatibility with all healthcare system records, throughout
4.1.3 Nosologically Sound—The nomenclature classifica- the United States, for longitudinal record file creation and for
tion system should be logical, in line with modern nosology put information transfer.
forward in related current textbooks and scientific publications. 4.1.10.1 The nomenclature should also be compatible with
4.1.4 Current—Clinical terminology shall be viewed as a other text processing tools such as nonclinical word/phrase
dynamic aggregate of terms with a constant addition of new lexicons.
terms and with adjustment of altered meaning or classifica- 4.1.10.2 The nomenclature should also be compatible with
tions. This calls for frequent purposeful updating. However, the various knowledge managers such as the National Library
such updating shall conserve continuity between the term of Medicine’s search listings initiative, knowledge coupling
previous to the change and the post-change term(s), in order to databases, and other clinical information distributors.
protect the database. Updating should be regular, publicized, 4.1.10.3 Compatibility of the clinical nomenclature should
and frequent. also include the terminology of periclinical terminology do-
4.1.5 Computer-Based— For effective support of clinical mains such as psychology, sociology, legal, and clinical terms,
text analysis, and for efficient updating, the nomenclature because these terms may also occur in the clinical record.
should be computer-based.
4.1.6 Software Supported—The nomenclature should have 5. Significance and Use
explicit data format designed for use in a computerized 5.1 Terminology guidelines are essential for precise inter-
environment, and the nomenclature software should permit human communication. A guide for clinical terminology has an
efficient and easy retrieval and matching of any clinical term. additional task: to maintain compatibility among health records
4.1.7 Integrated—The nomenclature should be able to be generated at different times, and at different geographic loca-
cross-referenced with other terminology listings currently in tions. Current lack of such clinical terminology guidelines is a
use and future terminology listings such as the International barrier that prevents progress in the development of electronic
Classification of Diseases (ICD-9CM), Current Procedural health records.

RELATED MATERIAL

(1) American Medical Association, Standard Nomenclature of Dis- (8) Martin, K. S. and Scheet, N. J., The Omaha System: Applications
eases and Operations. for Community Health Nursing, Philadelphia, PA W. B. Saunders,
(2) College of American Pathologists, The Systematized Nomenclature 1995.
of Medicine, SNOMED International, 1993. (9) McCloskey, J. C. and Bulechek, G. M., eds., Nursing Interventions
(3) College of American Pathologists, Systematized Nomenclature of Classification, Mosby-Yearbook, St. Louis, MO, 1992.
Pathology, Wells, A., ed., Chicago, IL, 1965.
(10) North American Nursing Diagnosis Association, NANDA Nursing
(4) Commission of Professional and Hospital Activities, International
Diagnoses: Definition and Classification, Philadelphia, PA, the
Classification of Diseases, 9th edition, Clinical Modification, 1978.
Association. McCloskey, J. C. and Bulechek, G. M., eds. Nursing
(5) Gabrieli, E. R., “Need for Standards in Clinical Communications,”
Interventions Classification, Mosby-Yearbook, St. Louis, MO,
Topics; Health Record Management, 11, 1991, pp. 27–36.
1992.
(6) Gabrieli, E. R., “A New Electronic Clinical Nomenclature,”
Journal of Clinical Systems, 13, 1984, 355–73. (11) Saba, V. K., Home Health Care Classification, Washington, DC,
(7) Gabrieli, E. R., “Standardized Laboratory Testing Name Nomen- 1992.
clature: A Requirement for Database Exchange,” Clinical Labora- (12) Thompson, E. T., ed., Standard Nomenclature of Diseases and
tory Management, January/February 1992. Operations, Fifth ed., McGraw-Hill Book Co., NY, 1952.

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