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|Requirement ID:||Req-256: Manage Consents and Authorizations||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Consents and Authorizations||Manage Structured Health Record Information|
|Description:||STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
|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, Parents and Guardians and Family Relationship Data, Primary Care Management, Records Management, Security and Confidentiality, Special Terminology and Information||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||DC.1.1.3, S.2.2.2, S.3.5.1, S.3.5.4, IN.1.5, IN.1.8, IN.1.9, IN.2.2, IN.2.4, IN.2.5.1, IN.2.5.2, IN.6|