1. EHR System Function and Information Model (EHR-S FIM is based on EHR-S FM R2.0) CP.3.3 Manage Clinical Documents and Notes aka DC in EHR-S FM R1.1
, facilitator
January 21, 2012 – Original
February 24, 2012 – Last Update
Call for Participation
This work is being done by the HL7 EHR Interoperability Work-group,
meeting every Tuesday at 4PM ET, dial-in: , Passcode: #
 The most current artifacts are at:
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2. 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 and status, according to scope of practice, organizational policy and/or jurisdictional law. 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 and documents. The system may manage, as lists, patients’ follow-up needs-and-status.
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CP.3.3 Manage Clinical Documents and Notes Activities Mapped-to System-Components
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CP.3.3 Manage Clinical Documents and Notes Conceptual Information Model (CIM) Mapped to EHR-S Functions
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5. CP.3.3 Manage Clinical Documents and Notes Conceptual Data Model (CDM)
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CP.3.3 Manage Clinical Documents and Notes CDM Requirements-Traceability
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7. CP.3.3 Manage Clinical Documents and Notes Requirements Traceability
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8. CP.3.3 Manage Clinical Documents and Notes “See Also” Dependencies
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9. Action Verb Hierarches
Manage (Data)
Capture
Maintain
Render
Exchange
Determine
Manage- Data- Visibility
Auto-Populate
Enter
Import
Receive
Store
Update
Remove
Extract
Present
Transmit
Export
Analyze
Decide
De-Identify
Hide
Mask
Re-Identify
Unhide
Unmask
Archive
Backup
Decrypt
Encrypt
Recover
Restore
Save
Annotate
Attest
Edit
Harmonize
Integrate
Link
Tag
Delete
Purge
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Archive
Older slides
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11. 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, 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.
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12. CP.3.3 Manage Clinical Documents and Notes Requirements
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).
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).
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13. CP.3.3 Manage Clinical Documents and Notes “See Also” Dependencies
CP.3.1 Conduct Assessments
POP.6 Measurement, Analysis, Research and Reports
OVERARCHING:
Trust Infrastructure
Record Infrastructure