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

: CP.3 Manage Clinical Documentation (Header) - XML Representation

Page standards status: Informative

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<Requirements xmlns="http://hl7.org/fhir">
  <id value="EHRSFMR2-CP.3"/>
  <meta>
    <profile
             value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMHeader"/>
  </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>Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering.</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>Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers.</p>
</div></span>
    

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

    
    <table id="statements" class="grid dict">
        
    </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-CP.3"/>
  <version value="2.1.1-ballot"/>
  <name value="CP_3_Manage_Clinical_Documentation"/>
  <title value="CP.3 Manage Clinical Documentation (Header)"/>
  <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="Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <purpose
           value="Clinical documentation includes all documentation that the clinician may capture during the course of an encounter with the patient or relevant to the patient. This includes assessments, clinical measurements, clinical documents and notes, patient-specific care and treatment plans. Management of clinical documentation also includes the acknowledgement and amendments of documentation provided by other providers."/>
</Requirements>