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Req-560: Capture Patient-Originated Data | Req-1096: Distinguish patient sourced data |
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2013 Format | 2013 Format |
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Capture Patient-Originated Data | Distinguish patient sourced data |
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STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record. DESCRIPTION: It is critically important to be able to distinguish patient-originated data that is either provided or entered by a patient from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-originated data intended for use by providers will be available for their use. Data about the patient may be appropriately provided by: 1. the patient 2. a surrogate (parent, spouse, guardian) or 3. an informant (teacher, lawyer, case worker). An electronic health record may provide the ability for direct data entry by any of these. Patient-originated data may also be captured by devices and transmitted for inclusion into the electronic health record. Data entered by any of these must be stored with source information. A provider must authenticate patient-originated data included in the patient's legal health record. |
The system SHALL clearly distinguish patient sourced/entered data from data received from a clinical system. |
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Patient Portals - PHR | Patient Portals - PHR |
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HL7 EHR FM R1 | SME |
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High | |
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Function | Normative Statements |
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SHALL | |
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no | no |
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Released | Released |
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