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Req-560: Capture Patient-Originated Data
Release Package: 2013 Format

Release Package:

2013 Format

Requirement ID:



Capture Patient-Originated Data


STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish patient-originated data that is either provided or entered by a patient from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-originated data intended for use by providers will be available for their use.
Data about the patient may be appropriately provided by:
1. the patient
2. a surrogate (parent, spouse, guardian) or
3. an informant (teacher, lawyer, case worker).
An electronic health record may provide the ability for direct data entry by any of these.
Patient-originated data may also be captured by devices and transmitted for inclusion into the electronic health record.
Data entered by any of these must be stored with source information. A provider must authenticate patient-originated data included in the patient's legal health record.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-560 Is Child Of 2013 Format Req-104 Data and Documentation From External Sources Header Not Applicable Compare
Req-560 Is Parent Of 2013 Format Req-525 Ability to allow parents/legal guardians and children add any relevant additional health information Normative Statements SHOULD Compare
Req-560 Is Parent Of 2013 Format Req-1096 Distinguish patient sourced data Normative Statements SHALL Compare

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Last Updated 04/13/2016
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