Personal Health Record System Functional Model, Release 2
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: PH.6.4 Data and Documentation from External Clinical Sources (Function) - JSON Representation

Active as of 2024-01-31

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{
  "resourceType" : "Requirements",
  "id" : "PHRSFMR2-PH.6.4",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/ehrs/StructureDefinition/FMFunction"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#03</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\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 capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\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 render notes based on filters, search, or sort criteria.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#06</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\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 exchange data using documentation templates.</p>\n</div></span>\n                \n\n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
  },
  "url" : "http://hl7.org/ehrs/Requirements/PHRSFMR2-PH.6.4",
  "version" : "0.1.0",
  "name" : "PH_6_4_Data_and_Documentation_from_External_Clinical_Sources",
  "title" : "PH.6.4 Data and Documentation from External Clinical Sources (Function)",
  "status" : "active",
  "date" : "2024-01-31T14:45:34+00:00",
  "publisher" : "EHR WG",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description" : "Most encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents.\r\n\r\nExample(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.",
  "statement" : [
    {
      "key" : "PHRSFMR2-PH.6.4-01",
      "label" : "PH.6.4#01",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : true,
      "requirement" : "IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law."
    },
    {
      "key" : "PHRSFMR2-PH.6.4-02",
      "label" : "PH.6.4#02",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : false,
      "requirement" : "The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law."
    },
    {
      "key" : "PHRSFMR2-PH.6.4-03",
      "label" : "PH.6.4#03",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results."
    },
    {
      "key" : "PHRSFMR2-PH.6.4-04",
      "label" : "PH.6.4#04",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : true,
      "requirement" : "IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder."
    },
    {
      "key" : "PHRSFMR2-PH.6.4-05",
      "label" : "PH.6.4#05",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to render notes based on filters, search, or sort criteria."
    },
    {
      "key" : "PHRSFMR2-PH.6.4-06",
      "label" : "PH.6.4#06",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to exchange data using documentation templates."
    }
  ]
}