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|Requirement ID:||Req-264: Manage Results||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Results||Manage Structured Health Record Information|
|Description:||STATEMENT: Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
DESCRIPTION: Results of tests are presented in an easily accessible manner to the appropriate providers. Flow sheets, graphs, or other tools allow care providers to view or uncover trends in test data over time. In addition to making results viewable, it is often necessary to send results to appropriate providers using electronic messaging systems, pagers, or other mechanisms. Documentation of notification is accommodated. Results may also be routed to patients electronically or by letter.
|STATEMENT: Create, capture, and maintain structured health record information.
DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.
Examples of structured health information include:
- patient address (non-codified, but discrete field)
- diastolic blood pressure (numeric)
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers
Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHRS (e.g., Subjective/Objective/Assessment/Plan) but unstructured in others.
|Topic Area(s):||Primary Care Management, Records Management||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||DC.2.4.3, S.2.2.1, S.3.7.1, IN.1.6, IN.1.7, IN.2.4, IN.2.5.1, IN.2.5.2, IN.6|