| Package | hl7.ehrs.ehrsfmr21 |
| Type | Requirements |
| Id | Id |
| FHIR Version | R5 |
| Source | http://hl7.org/ehrs/https://build.fhir.org/ig/mvdzel/ehrsfm-fhir-r5/Requirements-EHRSFMR2.1-CPS.3.12.html |
| Url | http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CPS.3.12 |
| Version | 2.1.0 |
| Status | active |
| Date | 2024-11-26T16:30:50+00:00 |
| Name | CPS_3_12_Manage_Health_Information_Record_Quality |
| Title | CPS.3.12 Manage Health Information Record Quality (Function) |
| Experimental | False |
| Realm | uv |
| Authority | hl7 |
| Description | Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text. |
| Purpose | Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type. |
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Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.
Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.
| CPS.3.12#01 | SHOULD |
The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function. |
| CPS.3.12#02 | SHOULD |
The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function. |
| CPS.3.12#03 | SHOULD |
The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function. |
| CPS.3.12#04 | SHOULD |
The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation. |
| CPS.3.12#05 | SHOULD |
The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function. |
| CPS.3.12#06 | SHOULD |
The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered). |
| CPS.3.12#07 | SHOULD |
The system SHOULD determine and present the appropriate template when the associated shortcut is entered. |
| CPS.3.12#08 | MAY |
The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros. |
| CPS.3.12#09 | MAY |
The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros. |
FHIR{
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"id" : "EHRSFMR2.1-CPS.3.12",
"meta" : {
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span id=\"description\"><b>Statement <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b> <div><p>Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.</p>\n</div></span>\n\n \n <span id=\"purpose\"><b>Description <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Informative Content\" class=\"informative-flag\">I</a>:</b> <div><p>Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.</p>\n</div></span>\n \n\n \n\n \n <span id=\"requirements\"><b>Criteria <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b></span>\n \n <table id=\"statements\" class=\"grid dict\">\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#01</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#02</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#03</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#04</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#05</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#06</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered).</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#07</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>SHOULD</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system SHOULD determine and present the appropriate template when the associated shortcut is entered.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#08</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n <tr>\n <td style=\"padding-left: 4px;\">\n \n <span>CPS.3.12#09</span>\n \n </td>\n <td style=\"padding-left: 4px;\">\n \n \n \n <span>MAY</span>\n \n </td>\n <td style=\"padding-left: 4px;\" class=\"requirement\">\n \n <span><div><p>The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.</p>\n</div></span>\n \n \n </td>\n </tr>\n \n </table>\n</div>"
},
"url" : "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CPS.3.12",
"version" : "2.1.0",
"name" : "CPS_3_12_Manage_Health_Information_Record_Quality",
"title" : "CPS.3.12 Manage Health Information Record Quality (Function)",
"status" : "active",
"date" : "2024-11-26T16:30:50+00:00",
"publisher" : "EHR WG",
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"description" : "Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.",
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"coding" : [
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"code" : "001",
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"label" : "CPS.3.12#01",
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"conditionality" : false,
"requirement" : "The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function."
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"requirement" : "The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function."
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{
"extension" : [
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"url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
"valueBoolean" : false
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"key" : "EHRSFMR2.1-CPS.3.12-03",
"label" : "CPS.3.12#03",
"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function."
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"requirement" : "The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation."
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"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function."
},
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"valueBoolean" : false
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"key" : "EHRSFMR2.1-CPS.3.12-06",
"label" : "CPS.3.12#06",
"conformance" : [
"SHOULD"
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"conditionality" : false,
"requirement" : "The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered)."
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"key" : "EHRSFMR2.1-CPS.3.12-07",
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"conformance" : [
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"conditionality" : false,
"requirement" : "The system SHOULD determine and present the appropriate template when the associated shortcut is entered."
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"valueBoolean" : false
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"requirement" : "The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros."
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]
}
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