HL7 Personal Health Record System Functional Model, Release 2
2.0.1-ballot - Normative Ballot

HL7 Personal Health Record System Functional Model, Release 2, published by EHR WG. This guide is not an authorized publication; it is the continuous build for version 2.0.1-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/phrsfm-ig/ and changes regularly. See the Directory of published versions

: PH.6.4 Data and Documentation from External Clinical Sources (Function) - JSON Representation

Page standards status: Informative

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{
  "resourceType" : "Requirements",
  "id" : "PHRSFMR2-PH.6.4",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/FMFunction"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <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>The system should capture, index, and store documentation related to the encounter.</p>\n</div></span>\n\n    \n    <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>Most encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents.</p>\n<p>Example(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.</p>\n</div></span>\n    \n\n    \n    \n    \n\n    \n    <span id=\"requirements\"><b>Criteria <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b></span>\n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                <i>conditional</i>\n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#03</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                <i>conditional</i>\n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to render notes based on filters, search, or sort criteria.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>PH.6.4#06</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to exchange data using documentation templates.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "ehr"
    }
  ],
  "url" : "http://hl7.org/ehrs/uv/phrsfmr2/Requirements/PHRSFMR2-PH.6.4",
  "version" : "2.0.1-ballot",
  "name" : "PH_6_4_Data_and_Documentation_from_External_Clinical_Sources",
  "title" : "PH.6.4 Data and Documentation from External Clinical Sources (Function)",
  "status" : "active",
  "date" : "2025-08-29T14:03:44+00:00",
  "publisher" : "EHR WG",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description" : "The system should capture, index, and store documentation related to the encounter.",
  "purpose" : "Most encounters generate documentation that can be captured in the PHR-S. Additional supporting data such as diagnostic reports or consultations may be included. A prolonged hospitalization encounter may encompass numerous structured or unstructured documents.\r\n\r\nExample(s): The system should capture, index, and store encounter information, including the encounter document or summary, laboratory results, radiographic images, PACS, EKG, and scanned documents.",
  "statement" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-01",
      "label" : "PH.6.4#01",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : true,
      "requirement" : "IF information is received through any electronic interface or is electronically referenced, THEN the system SHALL present it upon request, according to organizational policy and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-02",
      "label" : "PH.6.4#02",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : false,
      "requirement" : "The system SHALL provide the ability to capture externally-sourced electronic clinical documentation including original, updates and addenda, according to organizational policy and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-03",
      "label" : "PH.6.4#03",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to capture and maintain externally-sourced electronic clinical documentation and annotations with structured content including problems, diagnoses, office visit, phone communication, e-mail consultations and laboratory results."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-04",
      "label" : "PH.6.4#04",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : true,
      "requirement" : "IF externally-sourced electronic clinical documentation is captured from encounters with providers, THEN the system SHALL provide the ability to present that documentation to the PHR Account Holder."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-05",
      "label" : "PH.6.4#05",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to render notes based on filters, search, or sort criteria."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "PHRSFMR2-PH.6.4-06",
      "label" : "PH.6.4#06",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to exchange data using documentation templates."
    }
  ]
}