The system SHALL determine that clinical terms and coded clinical data exist in an approved standard terminology.

The system SHOULD provide the ability to receive and transmit healthcare data using formal standard information models and approved standard terminologies according to scope of practice, organizational policy, and/or jurisdictional law.

The system SHOULD provide the ability to manage data using a formal standard terminology model according to scope of practice, organizational policy, and/or jurisdictional law.

The system SHOULD provide the ability to determine hierarchical inferences (e.g., subsumption across coded terminology concepts that are expressed using standard terminology models).

The system SHALL provide the ability to manage terminology assets and supporting tools (internal or external to the PHR-S).

IF there is no recognized-standard terminology model available, THEN the system MAY provide the ability to manage data using a locally-defined standard terminology model.

The system SHOULD provide the ability to capture information into structured data formats using approved standard terminologies without the user requiring knowledge of the terminologies used.

The system SHOULD provide the ability to enter data using content that is common to the user, and allow for collection and presentation of text form data to meet the pre-determined purposes of others. Text forms should exclude cryptic or uncommon abbreviations.

The system SHOULD provide the ability to present standard terminology terms in a language which is appropriate for the user.

The system SHALL provide the ability to exchange data with other systems (internal or external to the PHR-S) using approved standard terminologies.