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) - JSON Representation

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    {
      "resourceType" : "Requirements",
      "id" : "PHRSFMR2-PH.6.4",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/ehrs/uv/phrsfmr2/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>The system should capture, index, and store documentation related to the encounter.</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>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>\n<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>\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>PH.6.4#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                <i>conditional</i>\n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <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>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <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>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#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 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>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                <i>conditional</i>\n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <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>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#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 provide the ability to render notes based on filters, search, or sort criteria.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#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 exchange data using documentation templates.</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/phrsfmr2/Requirements/PHRSFMR2-PH.6.4",
      "version" : "2.0.1-ballot",
      "name" : "PH_6_4_Data_and_Documentation_from_External_Clinical_Sources",
      "title" : "PH.6.4 Data and Documentation from External Clinical Sources (Function)",
      "status" : "active",
      "date" : "2025-04-04T11:42:51+11:00",
      "publisher" : "EHR WG",
      "contact" : [
        {
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/ehr"
            }
          ]
        }
      ],
      "description" : "The system should capture, index, and store documentation related to the encounter.",
      "purpose" : "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.\r\n\r\nExample(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" : true
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-01",
          "label" : "PH.6.4#01",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : true,
          "requirement" : "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."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : true
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-02",
          "label" : "PH.6.4#02",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "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."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-03",
          "label" : "PH.6.4#03",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "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."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-04",
          "label" : "PH.6.4#04",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : true,
          "requirement" : "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."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-05",
          "label" : "PH.6.4#05",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to render notes based on filters, search, or sort criteria."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "PHRSFMR2-PH.6.4-06",
          "label" : "PH.6.4#06",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to exchange data using documentation templates."
        }
      ]
    }