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Packagehl7.ehrs.us.dhfpr2
Resource TypeRequirements
IdRequirements-DHFPR2-CP.3.json
FHIR VersionR5
Sourcehttps://build.fhir.org/ig/HL7/dhfp-ig/Requirements-DHFPR2-CP.3.html
URLhttp://hl7.org/ehrs/us/dhfpr2/Requirements/DHFPR2-CP.3
Version2.0.0-ballot
Statusactive
Date2025-12-19T08:44:27+00:00
NameCP_3_Manage_Clinical_Documentation
TitleCP.3 Manage Clinical Documentation (Header)
Realmus
Authorityhl7
DescriptionClinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.
PurposeClinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers.

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Narrative

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Description I:

Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers.


Source1

{
  "resourceType": "Requirements",
  "id": "DHFPR2-CP.3",
  "meta": {
    "profile": [
      "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMHeader"
    ]
  },
  "language": "en",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "informative"
    },
    {
      "url": "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info",
      "valueCode": "NC"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "ehr"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger": 1,
      "_valueInteger": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://hl7.org/ehrs/us/dhfpr2/ImplementationGuide/hl7.ehrs.us.dhfpr2"
          }
        ]
      }
    }
  ],
  "url": "http://hl7.org/ehrs/us/dhfpr2/Requirements/DHFPR2-CP.3",
  "version": "2.0.0-ballot",
  "name": "CP_3_Manage_Clinical_Documentation",
  "title": "CP.3 Manage Clinical Documentation (Header)",
  "status": "active",
  "date": "2025-12-19T08:44:27+00:00",
  "publisher": "HL7 International / Electronic Health Records",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description": "Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US"
        }
      ]
    }
  ],
  "purpose": "Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers.",
  "derivedFrom": [
    "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.3"
  ]
}