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|Requirement ID:||Req-262: Manage Patient-Specific Care and Treatment Plans||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Patient-Specific Care and Treatment Plans||Manage Structured Health Record Information|
|Description:||STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
|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):||Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive Care||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||DC.3.1.1, DC.3.1.2, DC.3.1.3, IN.2.2, IN.2.5.1, IN.2.5.2, IN.6|