You are viewing the Abridged Children's EHR Format.
To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
|Requirement ID:||Req-255: Manage Clinical Documents and Notes||Req-281: Documentation of Care, Measurements and Results|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Clinical Documents and Notes||Documentation of Care, Measurements and Results|
|Description:||STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphical, audio, etc.. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations.
|System will document Care, Measurements and Results|
|Topic Area(s):||Primary Care Management, Records Management, Well Child/Preventive Care||Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Records Management, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||IN.2.2, IN.2.5.1, IN.2.5.2|