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

: CPS.3.12 Manage Health Information Record Quality (Function) - TTL Representation

Active as of 2024-06-01

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Requirements ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "EHRSFMR2.1-CPS.3.12"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/ehrs/StructureDefinition/FMFunction"^^xsd:anyURI ;
fhir:link <http://hl7.org/ehrs/StructureDefinition/FMFunction>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <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>Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.</p>\n</div></span>\n\n    \n    <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>Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.</p>\n</div></span>\n    \n\n    \n\n    \n    <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>\n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#03</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#06</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered).</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#07</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD determine and present the appropriate template when the associated shortcut is entered.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#08</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CPS.3.12#09</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
  ] ; # 
  fhir:url [ fhir:v "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CPS.3.12"^^xsd:anyURI] ; # 
  fhir:version [ fhir:v "0.14.0"] ; # 
  fhir:name [ fhir:v "CPS_3_12_Manage_Health_Information_Record_Quality"] ; # 
  fhir:title [ fhir:v "CPS.3.12 Manage Health Information Record Quality (Function)"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:date [ fhir:v "2024-06-01T08:34:10+00:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "EHR WG"] ; # 
  fhir:contact ( [
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/ehr" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text."] ; # 
  fhir:purpose [ fhir:v "Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type."] ; # 
  fhir:statement ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-01" ] ;
fhir:label [ fhir:v "CPS.3.12#01" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-02" ] ;
fhir:label [ fhir:v "CPS.3.12#02" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-03" ] ;
fhir:label [ fhir:v "CPS.3.12#03" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-04" ] ;
fhir:label [ fhir:v "CPS.3.12#04" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-05" ] ;
fhir:label [ fhir:v "CPS.3.12#05" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-06" ] ;
fhir:label [ fhir:v "CPS.3.12#06" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered)." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-07" ] ;
fhir:label [ fhir:v "CPS.3.12#07" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system SHOULD determine and present the appropriate template when the associated shortcut is entered." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-08" ] ;
fhir:label [ fhir:v "CPS.3.12#08" ] ;
    ( fhir:conformance [ fhir:v "MAY" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] ) ;
fhir:key [ fhir:v "EHRSFMR2.1-CPS.3.12-09" ] ;
fhir:label [ fhir:v "CPS.3.12#09" ] ;
    ( fhir:conformance [ fhir:v "MAY" ] ) ;
fhir:conditionality [ fhir:v "false"^^xsd:boolean ] ;
fhir:requirement [ fhir:v "The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros." ]
  ] ) . #