HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1 - Normative

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 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

## : CPS.1.5 Manage Patient Encounter (Function)

Page standards status: Normative

Raw xml | Download

    <Requirements xmlns="http://hl7.org/fhir">
      <id value="EHRSFMR2-CPS.1.5"/>
      <meta>
        <profile
                 value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"/>
      </meta>
      <language value="en"/>
      <text>
        <status value="extensions"/>
        <div xml:lang="en" xmlns="http://www.w3.org/1999/xhtml" lang="en">

        <div id="description"><b>Description <a href="https://hl7.org/fhir/versions.html#std-process" title="Informative Content" class="informative-flag">I</a>:</b> <div><p>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.</p>
    <p>Tele-health encounters have unique requirements that may also be supported by the system.</p>
    </div></div>

        <div id="requirements"><b>Criteria <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b></div>

        <table id="statements" class="grid dict">

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#01
                </td>
                <td style="padding-left: 4px;">
                SHALL

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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.</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#02
                </td>
                <td style="padding-left: 4px;">
                SHOULD

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>The system SHOULD provide the ability to determine and render a notification that the patient requires a follow-up encounter.</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#03
                </td>
                <td style="padding-left: 4px;">
                SHOULD

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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).</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#04
                </td>
                <td style="padding-left: 4px;">
                SHOULD

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>The system SHOULD provide the ability to maintain and render administrative information relevant to an encounter.</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#05
                </td>
                <td style="padding-left: 4px;">
                SHOULD

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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).</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#06
                </td>
                <td style="padding-left: 4px;">
                MAY

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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.</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#07
                </td>
                <td style="padding-left: 4px;">
                SHALL

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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).</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#08
                </td>
                <td style="padding-left: 4px;">
                SHALL

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>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.</p>
    </div>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">
                CPS.1.5#09
                </td>
                <td style="padding-left: 4px;">
                MAY

                </td>
                <td style="padding-left: 4px;" class="requirement">
                    <div><p>The system MAY provide the ability to render an indication that the patient was referred for the visit or encounter.</p>
    </div>

                </td>
            </tr>

        </table>
    </div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
        <valueCode value="normative"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="ehr"/>
      </extension>
      <url value="http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CPS.1.5"/>
      <version value="2.1.1"/>
      <name value="CPS_1_5_Manage_Patient_Encounter"/>
      <title value="CPS.1.5 Manage Patient Encounter (Function)"/>
      <status value="active"/>
      <date value="2025-12-13T09:06:06+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="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
          <code value="001"/>
          <display value="World"/>
        </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."/>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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)."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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)."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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)."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.2#4"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.2#5"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-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."/>
      </statement>
    </Requirements>