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

## : CP.3 Manage Clinical Documentation (Header)

Page standards status: Normative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:Requirements ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "EHRSFMR2-CP.3"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMHeader"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMHeader>     ] )
      ] ; #
      fhir:language [ fhir:v "en"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<div xml:lang=\"en\" xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en\">\n    \n    \n    <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>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>\n</div></div>\n    \n    \n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n    </table>\n</div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "normative"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "ehr"     ]
      ] ) ; #
      fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.3"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.3>
      ] ; #
      fhir:version [ fhir:v "2.1.1"] ; #
      fhir:name [ fhir:v "CP_3_Manage_Clinical_Documentation"] ; #
      fhir:title [ fhir:v "CP.3 Manage Clinical Documentation (Header)"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:date [ fhir:v "2025-12-13T09:06:06+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Electronic Health Records"] ; #
      fhir:contact ( [
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/ehr" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "Clinical Documentation must be managed including the capture of the documentation during an encounter, maintenance and appropriate rendering."] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://unstats.un.org/unsd/methods/m49/m49.htm"^^xsd:anyURI ;
    fhir:l <http://unstats.un.org/unsd/methods/m49/m49.htm>       ] ;
    fhir:code [ fhir:v "001" ] ;
    fhir:display [ fhir:v "World" ]     ] )
      ] ) ; #
      fhir:purpose [ fhir:v "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."] . #