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) - XML Representation

Page standards status: Informative

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    <Requirements xmlns="http://hl7.org/fhir">
      <id value="EHRSFMR2-CPS.3.12"/>
      <meta>
        <profile
                 value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml">
        <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>
    </div></span>

        <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>
    </div></span>

        <span id="actors"><b>Actors:</b><br/> ehr</span>

        <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>

        <table id="statements" class="grid dict">

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#01</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#02</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#03</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#04</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#05</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#06</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#07</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD determine and present the appropriate template when the associated shortcut is entered.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#08</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CPS.3.12#09</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.</p>
    </div></span>

                </td>
            </tr>

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