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|Requirement ID:||Req-267: Produce a Summary Record of Care||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Produce a Summary Record of Care||Manage Structured Health Record Information|
|Description:||STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of care. Create service reports at the completion of an episode of care such as, but not limited to, discharge summaries and public health reports, without additional input from clinicians.
|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, Well Child/Preventive Care||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||S.2.2.1, IN.1.9, IN.2.4, IN.2.5.1, IN.2.5.2|