Stephen.Hufnagel@tma.osd.mil , facilitator January 21, 2011 DRAFT-A EHR System Function and Information Model (EHR-S FIM) CP.3.3 Manage Clinical Documents and Notes Stephen.Hufnagel@tma.osd.mil , facilitator January 21, 2011 DRAFT-A 12/30/2018 DRAFT WORKING DOCUMENT

CP.3.3 Manage Clinical Documents and Notes Statement: Create, addend ,amend, correct, authenticate, maintain, present and close, as needed, transcribed or directly-entered clinical documentation and notes. Description: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphic, audio, etc. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations. To facilitate the management and documentation on how providers are responding to incoming data on orders and results, there may also be some free text or formal record on the providers’ responsibility and/or standard choices for disposition, such as Reviewed and Filed, Recall Patient, or Future Follow Up. The system may also provide support for documenting the clinician’s differential diagnosis process. Example: (Notional Scenario) During an encounter, clinicians manage clinical documents and notes including their types (e.g., original, “update by amendment in order to correct”, and addenda) and status (e.g., preliminary, final. signed). Templates may be used for both unstructured-free-text or structured clinical-documents and notes. Clinicians may have the system render and/or link related types of clinical information (e.g., lab reports, differential diagnosis, disposition). The system may manage, as lists, patients’ follow-up needs-and-status. 12/30/2018 RED: delete, Blue: insert DRAFT WORKING DOCUMENT

CP.3.3 Manage Clinical Documents and Notes Requirements 1. The system SHALL provide the ability to capture and render clinical documentation (henceforth "documentation") including original, update by amendment in order to correct, and addenda. 2. The system SHALL provide the ability to capture free text documentation. 3. The system MAY present documentation templates (structured or free text) to facilitate creating documentation. 4. The system SHALL provide the ability to present other existing documentation within the patient's EHR while new creating new documentation. 5. The system SHOULD provide the ability to link documentation for a specific patient with a given event (e.g., office visit, phone communication, e-mail consult, lab result). 6. The system SHOULD provide the ability to render the list lists in a user defined sort order (Ref: CP.1.4 [Manage Problem List] cc#8). 6. The system SHOULD provide the ability to link encounters, orders, medical equipment, prosthetic/orthotic devices, medications, and notes to one or more problems (Ref: CP.1.4 [Manage Problem List] cc#9). 7. The system SHALL provide the ability to update documentation prior to finalizing it. 8. The system SHALL provide the ability to tag a document or note as final. 9. The system SHALL provide the ability to render the author(s) and authenticator(s) of documentation when the documentation is rendered. 11. The system SHALL provide the ability to render documents based on document metadata (e.g., note type, date range, facility, author, authenticator and patient). 12/30/2018 RED: delete, Blue: insert DRAFT WORKING DOCUMENT

CP.3.3 Manage Clinical Documents and Notes Dependencies CP.3.1 Conduct Assessments POP.6 Measurement, Analysis, Research and Reports OVERARCHING: Trust Infrastructure Record Infrastructure

CP.3.3 Manage Clinical Documents and Notes Requirements 14. The system MAY provide the ability for providers to capture clinical documentation using standard choices for disposition (e.g., reviewed and filed, recall patient, or future follow-up). 15. The system MAY provide the ability to capture, maintain and render the clinician’s differential diagnosis and the list of diagnoses that the clinician has considered in the evaluation of the patient. The system SHOULD provide the ability to render clinical documentation using an integrated charting or documentation tool (e.g., notes, flow-sheets, radiology views, or laboratory views). The system MAY provide the ability to capture clinical documentation using specialized charting tools for patient-specific requirements (e.g., age - neonates, pediatrics, geriatrics; condition - impaired renal function; medication). The system SHOULD provide the ability to capture, maintain and render transition-of-care related information. The system SHOULD provide the ability to tag the status of clinical documentation (e.g., preliminary, final, signed). The system SHOULD provide the ability to tag and render lists of patients requiring follow up contact (e.g., laboratory callbacks, radiology callbacks, left without being seen). The system SHOULD provide the ability to capture patient follow-up contact activities (e.g., laboratory callbacks, radiology callbacks, left without being seen). 12/30/2018 RED: delete, Blue: insert DRAFT WORKING DOCUMENT

DRAFT WORKING DOCUMENT CP.3.3 Manage Clinical Documents and Notes (Notional Scenario) based on EHR-S FM CP.1.6 Example 12/30/2018 DRAFT WORKING DOCUMENT

DRAFT WORKING DOCUMENT CP.3.3 Manage Clinical Documents and Notes Conceptual Information Model (CIM) 12/30/2018 DRAFT WORKING DOCUMENT

CP.3.3 Manage Clinical Documents and Notes Conceptual Data Model (CDM) 12/30/2018 DRAFT WORKING DOCUMENT