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Req-268: Manage Patient History
Release Package: 2013 Format


Release Package:

2013 Format

Requirement ID:

Req-268

Title:

Manage Patient History

Description:

STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band) or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-268 Is Child Of 2013 Format Req-103 Care Management Header Not Applicable Compare
Req-268 Is Related To 2013 Format Req-248 Capture Patient Health Data Derived from Administrative and Financial Data and Documentation Function Not Applicable Compare
Req-268 Is Related To 2013 Format Req-249 Health Record Output Function Not Applicable Compare
Req-268 Is Related To 2013 Format Req-276 Maintenance and Versioning of Standard Terminologies Function Not Applicable Compare
Req-268 Is Parent Of 2013 Format Req-506 Capture both presence and absence of conditions in history Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-507 Import / export data with Surgeon General’s Family Health History Tool Normative Statements MAY Compare
Req-268 Is Parent Of 2013 Format Req-517 Ability to access family history, including all parents Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-519 Ability to access, store, and retrieve the date, time, and place of the occurrence Normative Statements SHALL Compare
Req-268 Is Related To Req-700 Subject to Subject Relationship Header Not Applicable Compare
Req-268 Is Related To 2013 Format Req-702 Secure Data Routing Function Not Applicable Compare
Req-268 Is Related To 2013 Format Req-715 Standard Terminologies and Terminology Models Function Not Applicable Compare
Req-268 Is Related To 2013 Format Req-719 Interchange Agreements Function Not Applicable Compare
Req-268 Is Related To Req-766 Manage Unstructured Health Record Information Function Not Applicable Compare
Req-268 Is Related To 2013 Format Req-767 Manage Structured Health Record Information Function Not Applicable Compare
Req-268 Is Related To Req-770 Terminology Mapping Not Applicable Compare
Req-268 Is Related To Req-771 Interchange Standards Not Applicable Compare
Req-268 Is Related To 2013 Format Req-772 Interchange Standards Versioning and Maintenance Function Not Applicable Compare
Req-268 Is Parent Of 2013 Format Req-895 Birth History Header Not Applicable Compare
Req-268 Is Parent Of 2013 Format Req-974 Record age-appropriate interim/initial history Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-975 Record well-child data elements independently Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-976 Record well-child data elements Normative Statements MAY Compare
Req-268 Is Parent Of 2013 Format Req-988 Age-specific ROS Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1007 Copy and paste selected information from another medical record/chart Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1074 Capture patient relationships Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1075 Family history linkages Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1164 Pertinent family history for screening Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1175 Past history of abuse and neglect for the child Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1182 Store and retrieve restraining and visitation order information Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1188 Standardized CDC categorization for child abuse Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1192 Family history relationships Normative Statements SHALL Compare
Req-268 Is Parent Of 2013 Format Req-1194 EHR-documented abuse by caregivers Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1195 Externally documented abuse by caregivers Normative Statements MAY Compare
Req-268 Is Parent Of 2013 Format Req-1199 Family and patient history of substance abuse Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1200 Family and patient history of intimate partner violence Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1201 Family and patient history of suicidal ideation or depression Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1203 Navigate between family member charts Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1204 Import/export family member medical data Normative Statements MAY Compare
Req-268 Is Parent Of 2013 Format Req-1205 Import/export family member demographics Normative Statements SHOULD Compare
Req-268 Is Parent Of 2013 Format Req-1206 Authenticated external access to chart Normative Statements MAY Compare

Provenance:

HL7 EHR FM R1

Achievability:

Requirement Type:

Function

Shall/Should/May:

Critical/Core:

No

Status:

Released

Links:

Not Provided

See Also:

S.2.2.1, S.3.5, IN.1.7, IN.2.5.1, IN.2.5.2, IN.4.1, IN.4.2, IN.4.3, IN.5.1, IN.5.2, IN.5.4

Comments:

Not Provided

Additional Information:

Not Provided

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Last Updated 04/13/2016
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