United States Health Information Knowledgebase

 

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Children's EHR Format Requirement Comparison

(No Match) Requirement ID: Req-765: Store and Manage Health Record Information Req-767: Manage Structured Health Record Information
(Matches) Release Package: 2013 Format 2013 Format
(No Match) Title: Store and Manage Health Record Information Manage Structured Health Record Information
(No Match) Description: STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified data.

General examples of unstructured health record information include:
- text
- word processing document
- image
- multimedia

Specific examples include:
- text message to physician
- patient photo
- letter from family
- scanned image of insurance card
- dictated report (voice recording)

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 EHR-S (e.g., Subjective/Objective/Assessment/Plan) but unstructured in others.

Managing healthcare data includes capture, retrieval, deletion, correction, amendment, and augmentation. Augmentation refers to providing additional information regarding the healthcare data, which is not part of the data itself, e.g. linking patient consents or authorizations to the healthcare data of the patient.
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.
(Matches) Topic Area(s): Well Child/Preventive Care Well Child/Preventive Care
(Matches) Provenance: HL7 EHR FM R1 HL7 EHR FM R1
(Matches) Achievability:
(No Match) Requirement Type: Header Function
(Matches) Shall/Should/May:
(Matches) Critical/Core: no no
(Matches) Status: Released Released
(Matches) Links:
(Matches) See Also:
(Matches) Comments:
(Matches) Additional Information:
(Matches) Implementation Notes:
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