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|Requirement ID:||Req-104: Data and Documentation From External Sources||Req-560: Capture Patient-Originated Data|
|Release Package:||2013 Format||2013 Format|
|Title:||Data and Documentation From External Sources||Capture Patient-Originated Data|
|Description:||External sources are those outside the EHR system, including clinical, administrative, and financial information systems, other EHR systems, PHR systems, and data received through health information exchange networks.||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.
|Topic Area(s):||Birth Information, Parents and Guardians and Family Relationship Data, Patient Portals - PHR||Patient Portals - PHR|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|