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|Requirement ID:||Req-560: Capture Patient-Originated Data||Req-1096: Distinguish patient sourced data|
|Release Package:||2013 Format||2013 Format|
|Title:||Capture Patient-Originated Data||Distinguish patient sourced data|
|Description:||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.|
|Topic Area(s):||Patient Portals - PHR||Patient Portals - PHR|
|Provenance:||HL7 EHR FM R1||SME|
|Requirement Type:||Function||Normative Statements|