HL7 Personal Health Record System Functional Model, Release 2
2.0.1-ballot - Normative Ballot

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## : PH.6.4 Data and Documentation from External Clinical Sources (Function) - XML Representation

Page standards status: Informative

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    <Requirements xmlns="http://hl7.org/fhir">
      <id value="PHRSFMR2-PH.6.4"/>
      <meta>
        <profile
                 value="http://hl7.org/ehrs/uv/phrsfmr2/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>The system should capture, index, and store documentation related to the encounter.</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>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.</p>
    <p>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.</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>PH.6.4#01</span>

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

                    <i>dependent</i>

                    <i>conditional</i>

                    <span>SHALL</span>

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

                    <span><div><p>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.</p>
    </div></span>

                </td>
            </tr>

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

                    <span>PH.6.4#02</span>

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

                    <i>dependent</i>

                    <span>SHALL</span>

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

                    <span><div><p>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.</p>
    </div></span>

                </td>
            </tr>

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

                    <span>PH.6.4#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 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.</p>
    </div></span>

                </td>
            </tr>

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

                    <span>PH.6.4#04</span>

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

                    <i>conditional</i>

                    <span>SHALL</span>

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

                    <span><div><p>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.</p>
    </div></span>

                </td>
            </tr>

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

                    <span>PH.6.4#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 provide the ability to render notes based on filters, search, or sort criteria.</p>
    </div></span>

                </td>
            </tr>

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

                    <span>PH.6.4#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 exchange data using documentation templates.</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/phrsfmr2/Requirements/PHRSFMR2-PH.6.4"/>
      <version value="2.0.1-ballot"/>
      <name value="PH_6_4_Data_and_Documentation_from_External_Clinical_Sources"/>
      <title
             value="PH.6.4 Data and Documentation from External Clinical Sources (Function)"/>
      <status value="active"/>
      <date value="2025-04-04T11:42:51+11:00"/>
      <publisher value="EHR WG"/>
      <contact>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/ehr"/>
        </telecom>
      </contact>
      <description
                   value="The system should capture, index, and store documentation related to the encounter."/>
      <purpose
               value="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."/>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="true"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-01"/>
        <label value="PH.6.4#01"/>
        <conformance value="SHALL"/>
        <conditionality value="true"/>
        <requirement
                     value="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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="true"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-02"/>
        <label value="PH.6.4#02"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-03"/>
        <label value="PH.6.4#03"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-04"/>
        <label value="PH.6.4#04"/>
        <conformance value="SHALL"/>
        <conditionality value="true"/>
        <requirement
                     value="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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-05"/>
        <label value="PH.6.4#05"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to render notes based on filters, search, or sort criteria."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="PHRSFMR2-PH.6.4-06"/>
        <label value="PH.6.4#06"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to exchange data using documentation templates."/>
      </statement>
    </Requirements>