<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="Manage patient encounter information, including tele-health encounters, and support follow-up encounters."/> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166"/> <code value="US"/> </coding> </jurisdiction> <purpose value="Each encounter of the patient with the healthcare setting needs to be recorded and the information relevant to the distinct encounter managed. This information includes date and time of the encounter, providers involved, location(s), and the reason for the encounter etc. Additionally, follow-up encounters may require prior administrative and clinical information to be determined or captured, maintained and rendered. Tele-health encounters have unique requirements that may also be supported by the system."/> <derivedFrom value="http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CPS.1.5"/> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-01"/> <label value="CPS.1.5#01"/> <conformance value="SHALL"/> <conditionality value="false"/> <requirement value="The system SHALL provide the ability to manage information regarding a patient encounter, including a minimum of the following data: the date/time, providers, location, and reason for the encounter."/> <derivedFrom value="CPS.1.5#1"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-02"/> <label value="CPS.1.5#02"/> <conformance value="SHOULD"/> <conditionality value="false"/> <requirement value="The system SHOULD provide the ability to determine and render a notification that the patient requires a follow-up encounter."/> <derivedFrom value="CPS.1.5#2"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-03"/> <label value="CPS.1.5#03"/> <conformance value="SHOULD"/> <conditionality value="false"/> <requirement value="The system SHOULD provide the ability to determine or capture administrative information that is required for a follow-up encounter (e.g., co-payments, service location, prior authorization for a chest x-ray)."/> <derivedFrom value="CPS.1.5#3"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-04"/> <label value="CPS.1.5#04"/> <conformance value="SHOULD"/> <conditionality value="false"/> <requirement value="The system SHOULD provide the ability to maintain and render administrative information relevant to an encounter."/> <derivedFrom value="CPS.1.5#4"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-05"/> <label value="CPS.1.5#05"/> <conformance value="SHOULD"/> <conditionality value="false"/> <requirement value="The system SHOULD provide the ability to determine or capture clinical information that is required for a follow-up encounter (e.g., fasting requirements, pre-medications)."/> <derivedFrom value="CPS.1.5#5"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-06"/> <label value="CPS.1.5#06"/> <conformance value="MAY"/> <conditionality value="false"/> <requirement value="The system MAY provide the ability to manage a patient tele-health encounter including a minimum of the following data: date/time, providers, location and reason for the encounter."/> <derivedFrom value="CPS.1.5#6"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="C"/> </extension> <key value="DHFPR2-CPS.1.5-07"/> <label value="CPS.1.5#07"/> <conformance value="SHALL"/> <conditionality value="false"/> <requirement value="The system SHALL provide the ability to capture one or more complaints, presenting problems, or other reasons for the visit or encounter (e.g., chest pain, gunshot wound, and drug overdose during a single encounter). Dental examples include dental pain, swelling, bleeding, trauma, infection, and malocclusion."/> <derivedFrom value="CPS.1.5#7"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="C"/> </extension> <key value="DHFPR2-CPS.1.5-08"/> <label value="CPS.1.5#08"/> <conformance value="SHALL"/> <conditionality value="false"/> <requirement value="The system SHALL provide the ability to capture the primary reason (e.g., the Chief Complaint or the most important reason) for visit/encounter from the patient's perspective. Dental examples include dental pain, swelling, bleeding, trauma, infection, and malocclusion."/> <derivedFrom value="CPS.1.5#8"/> </statement> <statement> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"> <valueBoolean value="false"/> </extension> <extension url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info"> <valueCode value="NC"/> </extension> <key value="DHFPR2-CPS.1.5-09"/> <label value="CPS.1.5#09"/> <conformance value="MAY"/> <conditionality value="false"/> <requirement value="The system MAY provide the ability to render an indication that the patient was referred for the visit or encounter."/> <derivedFrom value="CPS.1.5#9"/> </statement> </Requirements>

Description I:

Each encounter of the patient with the healthcare setting needs to be recorded and the information relevant to the distinct encounter managed. This information includes date and time of the encounter, providers involved, location(s), and the reason for the encounter etc. Additionally, follow-up encounters may require prior administrative and clinical information to be determined or captured, maintained and rendered.

Tele-health encounters have unique requirements that may also be supported by the system.

Criteria N:

CPS.1.5#01

SHALL

The system SHALL provide the ability to manage information regarding a patient encounter, including a minimum of the following data: the date/time, providers, location, and reason for the encounter.

CPS.1.5#02

SHOULD

The system SHOULD provide the ability to determine and render a notification that the patient requires a follow-up encounter.

CPS.1.5#03

SHOULD

The system SHOULD provide the ability to determine or capture administrative information that is required for a follow-up encounter (e.g., co-payments, service location, prior authorization for a chest x-ray).

CPS.1.5#04

SHOULD

The system SHOULD provide the ability to maintain and render administrative information relevant to an encounter.

CPS.1.5#05

SHOULD

The system SHOULD provide the ability to determine or capture clinical information that is required for a follow-up encounter (e.g., fasting requirements, pre-medications).

CPS.1.5#06

MAY

The system MAY provide the ability to manage a patient tele-health encounter including a minimum of the following data: date/time, providers, location and reason for the encounter.

CPS.1.5#07

SHALL profiled

The system SHALL provide the ability to capture one or more complaints, presenting problems, or other reasons for the visit or encounter (e.g., chest pain, gunshot wound, and drug overdose during a single encounter). Dental examples include dental pain, swelling, bleeding, trauma, infection, and malocclusion.

CPS.1.5#08

SHALL profiled

The system SHALL provide the ability to capture the primary reason (e.g., the Chief Complaint or the most important reason) for visit/encounter from the patient's perspective. Dental examples include dental pain, swelling, bleeding, trauma, infection, and malocclusion.

CPS.1.5#09

MAY

The system MAY provide the ability to render an indication that the patient was referred for the visit or encounter.