Incorporate clinical documentation (computable and scanned) from external (to the system) sources.

Mechanisms for incorporating external clinical documentation (including identification of source) are available. External is considered anything that is external to the system - i.e. documents from the organization; but created in another system would be considered 'external' for the purposes of this function. Documentation incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate. This covers all types of documents received by the provider that would typically be incorporated into a medical record, including but not limited to faxes, referral authorizations, consultant reports, and patient/resident correspondence of a clinical nature. Intrinsic to the concept of electronic health records is the ability to exchange health information with other providers of health care services. Health information from these external sources needs to be received, stored in the patient record, and displayed upon request.

External data and documents addressed in the function include:

• Laboratory results received through an electronic interface - This information is to be received and stored in the resident record as discrete data, which means that each separate element of the data needs to be stored in its own field. Therefore, if laboratory results are received through an electronic interface, the results are received in the EHR and the laboratory test name, result (value), and unit of measure are correctly displayed as discrete data (vs. report format).

• Scanned documents received and stored as images (e.g., power of attorney forms, Living wills) - These scanned documents are indexed and can be retrieved based on the document type, date of the original document, and the date of scanning.

• Text-based outside reports (e.g., x-ray reports, hospital discharge summaries, history & physicals) - Any mechanism for capturing these reports is addendable: OCR, PDF, image file of report, etc.

• Clinical images from an external source (e.g., radiographic images, digital images from a diagnostic scan or graphical images) – These images may be stored within the system or be provided through direct linkage to an external source such as a hospital PACS system.

• Other forms of clinical results, such as wave files of EKG tracings.

• Medication detail (e.g., a medication history) from an external source such as a pharmacy, the patient, payer, or another provider - While the medication detail includes the medication name, strength, and SIG, this does not imply that the data will populate the medication module.

• Structured, text-based reports (e.g., medical summary text in a structured format).

• Standards-based structured, codified data (e.g., a Continuity of Care Document (CCD) with SNOMED CT).

Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate.