ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - CI Build

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Requirements: CP.3.5 Acknowledge/Amend Other Provider Documentation (Function)

Active as of 2024-11-23
Statement N:

Review and indicate or amend other caregiver notes as permitted.

 Description I:

Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted.

 Criteria N:
CP.3.5#01 dependent SHOULD

The system SHOULD provide the ability to tag documentation by another clinician as read according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#02 dependent MAY

The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#03 dependent SHALL

The system SHALL provide the ability for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#04 dependent SHOULD

The system SHOULD provide the ability to capture and render a co-signature of documentation according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.5#05 dependent MAY

The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law.