<status value="active"/> <date value="2025-12-19T08:44:27+00:00"/> <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="urn:iso:std:iso:3166"/> <code value="US"/> </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."/> <derivedFrom value="http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.3"/> </Requirements>

Description I:

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.