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
Page standards status: Informative |
{
"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."
}
]
}