HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1-ballot - Normative Ballot

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## : CPS.3.12 Manage Health Information Record Quality (Function) - JSON Representation

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    {
      "resourceType" : "Requirements",
      "id" : "EHRSFMR2-CPS.3.12",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"
        ]
      },
      "text" : {
        "status" : "extensions",
        "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    <span id=\"actors\"><b>Actors:</b><br/> ehr</span>\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>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "ehr"
        }
      ],
      "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CPS.3.12",
      "version" : "2.1.1-ballot",
      "name" : "CPS_3_12_Manage_Health_Information_Record_Quality",
      "title" : "CPS.3.12 Manage Health Information Record Quality (Function)",
      "status" : "active",
      "date" : "2025-04-04T11:04:36+11:00",
      "publisher" : "HL7 International / Electronic Health Records",
      "contact" : [
        {
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/ehr"
            }
          ]
        }
      ],
      "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.",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
              "code" : "001",
              "display" : "World"
            }
          ]
        }
      ],
      "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.",
      "statement" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-01",
          "label" : "CPS.3.12#01",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-02",
          "label" : "CPS.3.12#02",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-03",
          "label" : "CPS.3.12#03",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-04",
          "label" : "CPS.3.12#04",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-05",
          "label" : "CPS.3.12#05",
          "conformance" : [
            "SHOULD"
          ],
          "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."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-06",
          "label" : "CPS.3.12#06",
          "conformance" : [
            "SHOULD"
          ],
          "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)."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-07",
          "label" : "CPS.3.12#07",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD determine and present the appropriate template when the associated shortcut is entered."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-08",
          "label" : "CPS.3.12#08",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CPS.3.12-09",
          "label" : "CPS.3.12#09",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros."
        }
      ]
    }