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Req-765: Store and Manage Health Record Information
Release Package: 2013 Format


Release Package:

2013 Format

Requirement ID:

Req-765

Title:

Store and Manage Health Record Information

Description:

STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified data.

General examples of unstructured health record information include:
- text
- word processing document
- image
- multimedia

Specific examples include:
- text message to physician
- patient photo
- letter from family
- scanned image of insurance card
- dictated report (voice recording)

Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field)
- diastolic blood pressure (numeric)
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHR-S (e.g., Subjective/Objective/Assessment/Plan) but unstructured in others.

Managing healthcare data includes capture, retrieval, deletion, correction, amendment, and augmentation. Augmentation refers to providing additional information regarding the healthcare data, which is not part of the data itself, e.g. linking patient consents or authorizations to the healthcare data of the patient.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-765 Is Child Of 2013 Format Req-295 Health Record Information and Management Header Not Applicable Compare
Req-765 Is Parent Of Req-766 Manage Unstructured Health Record Information Function Not Applicable Compare
Req-765 Is Parent Of 2013 Format Req-767 Manage Structured Health Record Information Function Not Applicable Compare

Provenance:

HL7 EHR FM R1

Achievability:

Requirement Type:

Header

Shall/Should/May:

Critical/Core:

No

Status:

Released

Links:

Not Provided

See Also:

Not Provided

Comments:

Not Provided

Additional Information:

Not Provided

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Last Updated 04/13/2016
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