{ "resourceType" : "Requirements", "id" : "DHFPR2-CPS.3.12", "meta" : { "profile" : ["http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "
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Description I:

Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.

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Criteria N:
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\n CPS.3.12#01\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.

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\n CPS.3.12#02\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.

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\n CPS.3.12#03\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.

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\n CPS.3.12#04\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.

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\n CPS.3.12#05\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function.

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\n CPS.3.12#06\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered).

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\n CPS.3.12#07\n \n SHOULD\n \n \n \n \n \n \n \n \n

The system SHOULD determine and present the appropriate template when the associated shortcut is entered.

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\n CPS.3.12#08\n \n MAY\n \n \n \n \n \n \n \n \n

The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.

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\n CPS.3.12#09\n \n MAY\n \n \n \n \n \n \n \n \n

The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.

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" }, "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status", "valueCode" : "informative" }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode" : "ehr" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger" : 1, "_valueInteger" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom", "valueCanonical" : "http://hl7.org/ehrs/us/dhfpr2/ImplementationGuide/hl7.ehrs.us.dhfpr2" }] } }], "url" : "http://hl7.org/ehrs/us/dhfpr2/Requirements/DHFPR2-CPS.3.12", "version" : "2.0.0-ballot", "name" : "CPS_3_12_Manage_Health_Information_Record_Quality", "title" : "CPS.3.12 Manage Health Information Record Quality (Function)", "status" : "active", "date" : "2025-12-19T08:44:27+00:00", "publisher" : "HL7 International / Electronic Health Records", "contact" : [{ "telecom" : [{ "system" : "url", "value" : "http://www.hl7.org/Special/committees/ehr" }] }], "description" : "Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.", "jurisdiction" : [{ "coding" : [{ "system" : "urn:iso:std:iso:3166", "code" : "US" }] }], "purpose" : "Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.", "derivedFrom" : ["http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CPS.3.12"], "statement" : [{ "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-01", "label" : "CPS.3.12#01", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.", "derivedFrom" : "CPS.3.12#1" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-02", "label" : "CPS.3.12#02", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.", "derivedFrom" : "CPS.3.12#2" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-03", "label" : "CPS.3.12#03", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.", "derivedFrom" : "CPS.3.12#3" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-04", "label" : "CPS.3.12#04", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.", "derivedFrom" : "CPS.3.12#4" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-05", "label" : "CPS.3.12#05", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function.", "derivedFrom" : "CPS.3.12#5" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-06", "label" : "CPS.3.12#06", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered).", "derivedFrom" : "CPS.3.12#6" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-07", "label" : "CPS.3.12#07", "conformance" : ["SHOULD"], "conditionality" : false, "requirement" : "The system SHOULD determine and present the appropriate template when the associated shortcut is entered.", "derivedFrom" : "CPS.3.12#7" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-08", "label" : "CPS.3.12#08", "conformance" : ["MAY"], "conditionality" : false, "requirement" : "The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.", "derivedFrom" : "CPS.3.12#8" }, { "extension" : [{ "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent", "valueBoolean" : false }, { "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-change-info", "valueCode" : "NC" }], "key" : "DHFPR2-CPS.3.12-09", "label" : "CPS.3.12#09", "conformance" : ["MAY"], "conditionality" : false, "requirement" : "The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.", "derivedFrom" : "CPS.3.12#9" }] }