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

This page is part of the HL7 Electronic Health Record System Functional Model, Release 2.1.1 (v2.1.1-ballot: Normative 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Requirements: CP.3.5 Acknowledge/Amend Other Provider Documentation (Function)

Page standards status: Informative
Statement N:

Review and indicate or amend other caregiver notes as permitted.

 Description I:

Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted.

 Actors:
ehr Criteria N:
CP.3.5#01 dependent SHOULD

The system SHOULD provide the ability to tag documentation by another clinician as read according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#02 dependent MAY

The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#03 dependent SHALL

The system SHALL provide the ability for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#04 dependent SHOULD

The system SHOULD provide the ability to capture and render a co-signature of documentation according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#05 dependent MAY

The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law.