EHRS-FM IG

ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
0.14.0 - CI Build

ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1 - Local Development build (v0.14.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: CP.3.5 Acknowledge/Amend Other Provider Documentation (Function) - XML Representation

Active as of 2024-06-01

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<Requirements xmlns="http://hl7.org/fhir">
  <id value="EHRSFMR2.1-CP.3.5"/>
  <meta>
    <profile value="http://hl7.org/ehrs/StructureDefinition/FMFunction"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
    <span id="description"><b>Statement <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b> <div><p>Review and indicate or amend other caregiver notes as permitted.</p>
</div></span>

    
    <span id="purpose"><b>Description <a href="https://hl7.org/fhir/versions.html#std-process" title="Informative Content" class="informative-flag">I</a>:</b> <div><p>Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted.</p>
</div></span>
    

    

    
    <span id="requirements"><b>Criteria <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b></span>
    
    <table id="statements" class="grid dict">
        
        <tr>
            <td style="padding-left: 4px;">
                
                <span>CP.3.5#01</span>
                
            </td>
            <td style="padding-left: 4px;">
                
                <i>dependent</i>
                
                
                
                <span>SHOULD</span>
                
            </td>
            <td style="padding-left: 4px;" class="requirement">
                
                <span><div><p>The system SHOULD provide the ability to tag documentation by another clinician as read according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
                
                
            </td>
        </tr>
        
        <tr>
            <td style="padding-left: 4px;">
                
                <span>CP.3.5#02</span>
                
            </td>
            <td style="padding-left: 4px;">
                
                <i>dependent</i>
                
                
                
                <span>MAY</span>
                
            </td>
            <td style="padding-left: 4px;" class="requirement">
                
                <span><div><p>The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
                
                
            </td>
        </tr>
        
        <tr>
            <td style="padding-left: 4px;">
                
                <span>CP.3.5#03</span>
                
            </td>
            <td style="padding-left: 4px;">
                
                <i>dependent</i>
                
                
                
                <span>SHALL</span>
                
            </td>
            <td style="padding-left: 4px;" class="requirement">
                
                <span><div><p>The system SHALL provide the ability for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
                
                
            </td>
        </tr>
        
        <tr>
            <td style="padding-left: 4px;">
                
                <span>CP.3.5#04</span>
                
            </td>
            <td style="padding-left: 4px;">
                
                <i>dependent</i>
                
                
                
                <span>SHOULD</span>
                
            </td>
            <td style="padding-left: 4px;" class="requirement">
                
                <span><div><p>The system SHOULD provide the ability to capture and render a co-signature of documentation according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
                
                
            </td>
        </tr>
        
        <tr>
            <td style="padding-left: 4px;">
                
                <span>CP.3.5#05</span>
                
            </td>
            <td style="padding-left: 4px;">
                
                <i>dependent</i>
                
                
                
                <span>MAY</span>
                
            </td>
            <td style="padding-left: 4px;" class="requirement">
                
                <span><div><p>The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
                
                
            </td>
        </tr>
        
    </table>
</div>
  </text>
  <url value="http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CP.3.5"/>
  <version value="0.14.0"/>
  <name value="CP_3_5_Acknowledge_Amend_Other_Provider_Documentation"/>
  <title
         value="CP.3.5 Acknowledge/Amend Other Provider Documentation (Function)"/>
  <status value="active"/>
  <date value="2024-06-01T08:34:10+00:00"/>
  <publisher value="EHR WG"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/ehr"/>
    </telecom>
  </contact>
  <description
               value="Review and indicate or amend other caregiver notes as permitted."/>
  <purpose
           value="Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted."/>
  <statement>
    <extension
               url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
      <valueBoolean value="true"/>
    </extension>
    <key value="EHRSFMR2.1-CP.3.5-01"/>
    <label value="CP.3.5#01"/>
    <conformance value="SHOULD"/>
    <conditionality value="false"/>
    <requirement
                 value="The system SHOULD provide the ability to tag documentation by another clinician as read according to scope of practice, organizational policy, and/or jurisdictional law."/>
  </statement>
  <statement>
    <extension
               url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
      <valueBoolean value="true"/>
    </extension>
    <key value="EHRSFMR2.1-CP.3.5-02"/>
    <label value="CP.3.5#02"/>
    <conformance value="MAY"/>
    <conditionality value="false"/>
    <requirement
                 value="The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, organizational policy, and/or jurisdictional law."/>
  </statement>
  <statement>
    <extension
               url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
      <valueBoolean value="true"/>
    </extension>
    <key value="EHRSFMR2.1-CP.3.5-03"/>
    <label value="CP.3.5#03"/>
    <conformance value="SHALL"/>
    <conditionality value="false"/>
    <requirement
                 value="The system SHALL provide the ability for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, organizational policy, and/or jurisdictional law."/>
  </statement>
  <statement>
    <extension
               url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
      <valueBoolean value="true"/>
    </extension>
    <key value="EHRSFMR2.1-CP.3.5-04"/>
    <label value="CP.3.5#04"/>
    <conformance value="SHOULD"/>
    <conditionality value="false"/>
    <requirement
                 value="The system SHOULD provide the ability to capture and render a co-signature of documentation according to scope of practice, organizational policy, and/or jurisdictional law."/>
  </statement>
  <statement>
    <extension
               url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
      <valueBoolean value="true"/>
    </extension>
    <key value="EHRSFMR2.1-CP.3.5-05"/>
    <label value="CP.3.5#05"/>
    <conformance value="MAY"/>
    <conditionality value="false"/>
    <requirement
                 value="The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law."/>
  </statement>
</Requirements>