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) - TTL Representation

Page standards status: Informative

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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 "PHRSFMR2-PH.6.4"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/FMFunction"^^xsd:anyURI ;
fhir:link <http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/FMFunction>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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>"^^rdf:XMLLiteral
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
fhir:value [
a fhir:code ;
fhir:v "ehr"     ]
  ] ) ; # 
  fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/Requirements/PHRSFMR2-PH.6.4"^^xsd:anyURI] ; # 
  fhir:version [ fhir:v "2.0.1-ballot"] ; # 
  fhir:name [ fhir:v "PH_6_4_Data_and_Documentation_from_External_Clinical_Sources"] ; # 
  fhir:title [ fhir:v "PH.6.4 Data and Documentation from External Clinical Sources (Function)"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:date [ fhir:v "2025-08-29T14:03:44+00:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "EHR WG"] ; # 
  fhir:contact ( [
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/ehr" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "The system should capture, index, and store documentation related to the encounter."] ; # 
  fhir:purpose [ fhir:v "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."] ; # 
  fhir:statement ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v true       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-01" ] ;
fhir:label [ fhir:v "PH.6.4#01" ] ;
    ( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v true ] ;
fhir:requirement [ fhir:v "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." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v true       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-02" ] ;
fhir:label [ fhir:v "PH.6.4#02" ] ;
    ( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v false ] ;
fhir:requirement [ fhir:v "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." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v false       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-03" ] ;
fhir:label [ fhir:v "PH.6.4#03" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v false ] ;
fhir:requirement [ fhir:v "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." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v false       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-04" ] ;
fhir:label [ fhir:v "PH.6.4#04" ] ;
    ( fhir:conformance [ fhir:v "SHALL" ] ) ;
fhir:conditionality [ fhir:v true ] ;
fhir:requirement [ fhir:v "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." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v false       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-05" ] ;
fhir:label [ fhir:v "PH.6.4#05" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v false ] ;
fhir:requirement [ fhir:v "The system SHOULD provide the ability to render notes based on filters, search, or sort criteria." ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/ehrs/uv/phrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ] ;
fhir:value [
a fhir:boolean ;
fhir:v false       ]     ] ) ;
fhir:key [ fhir:v "PHRSFMR2-PH.6.4-06" ] ;
fhir:label [ fhir:v "PH.6.4#06" ] ;
    ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
fhir:conditionality [ fhir:v false ] ;
fhir:requirement [ fhir:v "The system SHOULD provide the ability to exchange data using documentation templates." ]
  ] ) . #