HL7 Electronic Health Record System Functional Model, Release 2.1.1, published by HL7 International / Electronic Health Records. This guide is not an authorized publication; it is the continuous build for version 2.1.1-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ehrsfm-ig/ and changes regularly. See the Directory of published versions

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: 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>
    

    
    
    

    
    <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="2025-08-29T14:03:55+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="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>