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FHIR IG Statistics: Requirements/PHRSFMR2-PH.6.4

Packagehl7.ehrs.uv.phrsfmr2
TypeRequirements
IdPHRSFMR2-PH.6.4
FHIR VersionR5
Sourcehttp://hl7.org/ehrs/uv/phrsfmr2/https://build.fhir.org/ig/HL7/phrsfm-ig/Requirements-PHRSFMR2-PH.6.4.html
URLhttp://hl7.org/ehrs/uv/phrsfmr2/Requirements/PHRSFMR2-PH.6.4
Version2.0.1-ballot
Statusactive
Date2025-04-03T15:15:30+00:00
NamePH_6_4_Data_and_Documentation_from_External_Clinical_Sources
TitlePH.6.4 Data and Documentation from External Clinical Sources (Function)
Authorityhl7
DescriptionThe system should capture, index, and store documentation related to the encounter.
PurposeMost encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents. Example(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.

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Narrative

Note: links and images are rebased to the (stated) source

Statement N:

The system should capture, index, and store documentation related to the encounter.

Description I:

Most encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents.

Example(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.

Actors:
ehr
Criteria N:
PH.6.4#01 dependent conditional SHALL

IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law.

PH.6.4#02 dependent SHALL

The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law.

PH.6.4#03 SHOULD

The system SHOULD provide the ability to capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results.

PH.6.4#04 conditional SHALL

IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder.

PH.6.4#05 SHOULD

The system SHOULD provide the ability to render notes based on filters, search, or sort criteria.

PH.6.4#06 SHOULD

The system SHOULD provide the ability to exchange data using documentation templates.


Source

{
  "resourceType": "Requirements",
  "id": "PHRSFMR2-PH.6.4",
  "meta": {
    "profile": [
      "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/FMFunction"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "ehr"
    }
  ],
  "url": "http://hl7.org/ehrs/uv/phrsfmr2/Requirements/PHRSFMR2-PH.6.4",
  "version": "2.0.1-ballot",
  "name": "PH_6_4_Data_and_Documentation_from_External_Clinical_Sources",
  "title": "PH.6.4 Data and Documentation from External Clinical Sources (Function)",
  "status": "active",
  "date": "2025-04-03T15:15:30+00:00",
  "publisher": "EHR WG",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description": "The system should capture, index, and store documentation related to the encounter.",
  "purpose": "Most encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents.\r\n\r\nExample(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.",
  "statement": [
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": true
        }
      ],
      "key": "PHRSFMR2-PH.6.4-01",
      "label": "PH.6.4#01",
      "conformance": [
        "SHALL"
      ],
      "conditionality": true,
      "requirement": "IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": true
        }
      ],
      "key": "PHRSFMR2-PH.6.4-02",
      "label": "PH.6.4#02",
      "conformance": [
        "SHALL"
      ],
      "conditionality": false,
      "requirement": "The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "PHRSFMR2-PH.6.4-03",
      "label": "PH.6.4#03",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD provide the ability to capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "PHRSFMR2-PH.6.4-04",
      "label": "PH.6.4#04",
      "conformance": [
        "SHALL"
      ],
      "conditionality": true,
      "requirement": "IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "PHRSFMR2-PH.6.4-05",
      "label": "PH.6.4#05",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD provide the ability to render notes based on filters, search, or sort criteria."
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean": false
        }
      ],
      "key": "PHRSFMR2-PH.6.4-06",
      "label": "PH.6.4#06",
      "conformance": [
        "SHOULD"
      ],
      "conditionality": false,
      "requirement": "The system SHOULD provide the ability to exchange data using documentation templates."
    }
  ]
}