ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - CI Build

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Requirements: CPS.3.12 Manage Health Information Record Quality (Function)

Active as of 2024-11-23
Statement N:

Support grammatical and lexical integrity of the health record by providing medical spelling, thesaurus and grammar ready assistance during clinical documentation as well as enabling shortcuts for pre-defined text.

 Description I:

Users and patients will benefit from features that enable rapid checking of spelling and grammar, a medical thesaurus function as well as text shortcuts to expand pre-defined text during clinical documentation. A shortcut may also be defined to trigger a specific system function such as the opening of a pre-defined template. These functions may be defined at an enterprise level based on scope of practice, organizational policy, and/or jurisdictional law. However, pre-defined text may also be configured by provider or provider type.

 Criteria N:
CPS.3.12#01 SHOULD

The system SHOULD determine and present the correct medical spelling based on an integrated realm-based medical spelling function.
CPS.3.12#02 SHOULD

The system SHOULD determine and present the correct medical thesaurus based on an integrated realm-based medical thesaurus function.
CPS.3.12#03 SHOULD

The system SHOULD determine and present the correct medical grammar based on an integrated realm-based medical grammar function.
CPS.3.12#04 SHOULD

The system SHOULD determine and present the appropriate pre-defined text when an associated shortcut is entered during clinical documentation.
CPS.3.12#05 SHOULD

The system SHOULD determine and present personally pre-defined text when triggered by the associated macro based on an integrated personally pre-defined-text function.
CPS.3.12#06 SHOULD

The system SHOULD provide the ability to manage shortcut for the insertion of templates (e.g., insert new patient assessment template when Ctrl-A is entered).
CPS.3.12#07 SHOULD

The system SHOULD determine and present the appropriate template when the associated shortcut is entered.
CPS.3.12#08 MAY

The system MAY provide the ability to manage an integrated enterprise pre-defined text function and associated macros.
CPS.3.12#09 MAY

The system MAY provide the ability to manage an integrated personally pre-defined text function and associated macros.