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 Manage Clinical Documentation (Header) - XML Representation

Active as of 2024-06-01

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<Requirements xmlns="http://hl7.org/fhir">
  <id value="EHRSFMR2.1-CP.3"/>
  <meta>
    <profile value="http://hl7.org/ehrs/StructureDefinition/FMHeader"/>
  </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>Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.</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>Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers.</p>
</div></span>
    

    

    
    <table id="statements" class="grid dict">
        
    </table>
</div>
  </text>
  <url value="http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CP.3"/>
  <version value="0.14.0"/>
  <name value="CP_3_Manage_Clinical_Documentation"/>
  <title value="CP.3 Manage Clinical Documentation (Header)"/>
  <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="Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering."/>
  <purpose
           value="Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers."/>
</Requirements>