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|Requirement ID:||Req-122: Manage Patient Clinical Measurements||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Patient Clinical Measurements||Manage Structured Health Record Information|
|Description:||STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of care. Other clinical measures (such as expiratory flow rate, size of lesion, etc.) are captured and managed, and may be discrete data.
|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):||EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive Care||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||IN.2.5.1, IN.2.5.2|