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Req-255: Manage Clinical Documents and Notes
Release Package: 2013 Format


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:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-255 Is Related To 2013 Format Req-275 Auditable Records Function Not Applicable Compare
Req-255 Is Child Of 2013 Format Req-281 Documentation of Care, Measurements and Results Header Not Applicable Compare
Req-255 Is Parent Of 2013 Format Req-631 Templates to facilitate documentation Normative Statements SHOULD Compare
Req-255 Is Related To Req-766 Manage Unstructured Health Record Information Function Not Applicable Compare
Req-255 Is Related To 2013 Format Req-767 Manage Structured Health Record Information Function Not Applicable Compare

Provenance:

HL7 EHR FM R1

Achievability:

Requirement Type:

Function

Shall/Should/May:

Critical/Core:

No

Status:

Released

Links:

Not Provided

See Also:

IN.2.2, IN.2.5.1, IN.2.5.2

Comments:

Not Provided

Additional Information:

Not Provided

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Last Updated 04/13/2016
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