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

Publication Build: This will be filled in by the publication tooling

## Requirements: PH.6.4 Data and Documentation from External Clinical Sources (Function)

Page standards status: Informative

Statement N:

The system should capture, index, and store documentation related to the encounter.

Description I:

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.

Actors:
ehr Criteria N:

PH.6.4#01 | dependent conditional SHALL | 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.
PH.6.4#02 | dependent SHALL | 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.
PH.6.4#03 | SHOULD | 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.
PH.6.4#04 | conditional SHALL | 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.
PH.6.4#05 | SHOULD | The system SHOULD provide the ability to render notes based on filters, search, or sort criteria.
PH.6.4#06 | SHOULD | The system SHOULD provide the ability to exchange data using documentation templates.