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|Requirement ID:||Req-255: Manage Clinical Documents and Notes||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Clinical Documents and Notes||Manage Structured Health Record Information|
|Description:||STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphical, audio, etc.. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations.
|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||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||IN.2.2, IN.2.5.1, IN.2.5.2|