United States Health Information Knowledgebase

Release Package:

2013 Format

Requirement ID:

Req-255

Title:

Manage Clinical Documents and Notes

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.

Related Requirements:

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Provenance:

Achievability:

Requirement Type:

Shall/Should/May:

Critical/Core:

Status:

Released

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Comments:

Additional Information:

Not Provided