ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
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: CP.3.5 Acknowledge/Amend Other Provider Documentation (Function) - JSON Representation

Active as of 2024-11-26

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{
  "resourceType" : "Requirements",
  "id" : "EHRSFMR2.1-CP.3.5",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/ehrs/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>Review and indicate or amend other caregiver notes as permitted.</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>Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted.</p>\n</div></span>\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>CP.3.5#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\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 tag documentation by another clinician as read according to scope of practice, 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>CP.3.5#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, 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>CP.3.5#03</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 for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, 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>CP.3.5#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\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 render a co-signature of documentation according to scope of practice, 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>CP.3.5#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                <i>dependent</i>\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
  },
  "url" : "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CP.3.5",
  "version" : "2.1.0",
  "name" : "CP_3_5_Acknowledge_Amend_Other_Provider_Documentation",
  "title" : "CP.3.5 Acknowledge/Amend Other Provider Documentation (Function)",
  "status" : "active",
  "date" : "2024-11-26T16:30:50+00:00",
  "publisher" : "EHR WG",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/ehr"
        }
      ]
    }
  ],
  "description" : "Review and indicate or amend other caregiver notes as permitted.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code" : "001",
          "display" : "World"
        }
      ]
    }
  ],
  "purpose" : "Scan/review notes from physicians, nurses, technicians and other members of the health care team (e.g., Respiratory Therapist, Physical Therapist). Annotate for disparities, make additions/amendments and import when desired and permitted.",
  "statement" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "EHRSFMR2.1-CP.3.5-01",
      "label" : "CP.3.5#01",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to tag documentation by another clinician as read according to scope of practice, organizational policy, and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "EHRSFMR2.1-CP.3.5-02",
      "label" : "CP.3.5#02",
      "conformance" : [
        "MAY"
      ],
      "conditionality" : false,
      "requirement" : "The system MAY provide the ability to tag agreement or disagreement with documentation by another provider according to scope of practice, organizational policy, and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "EHRSFMR2.1-CP.3.5-03",
      "label" : "CP.3.5#03",
      "conformance" : [
        "SHALL"
      ],
      "conditionality" : false,
      "requirement" : "The system SHALL provide the ability for a user (e.g., supervising clinician) to annotate regarding his/her role in advising, and/or providing direct care according to scope of practice, organizational policy, and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "EHRSFMR2.1-CP.3.5-04",
      "label" : "CP.3.5#04",
      "conformance" : [
        "SHOULD"
      ],
      "conditionality" : false,
      "requirement" : "The system SHOULD provide the ability to capture and render a co-signature of documentation according to scope of practice, organizational policy, and/or jurisdictional law."
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/ehrs/StructureDefinition/requirements-dependent",
          "valueBoolean" : true
        }
      ],
      "key" : "EHRSFMR2.1-CP.3.5-05",
      "label" : "CP.3.5#05",
      "conformance" : [
        "MAY"
      ],
      "conditionality" : false,
      "requirement" : "The system MAY provide the ability to capture the approval of documentation that was captured by another user according to scope of practice, organizational policy, and/or jurisdictional law."
    }
  ]
}