{"schema":"https://ver.cy/schemas/card/1.0.0","id":"EM-HCP-08","code":"em-hcp-08","url":"https://ver.cy/models/em-hcp-08/","name":"Clinical document and record entry","alternateNames":[],"kind":"enterprise-contour","status":"published","version":"research-checkpoint","language":"en","classifiers":{"family":"Enterprise profiles","category":"Enterprise subject","entryKind":"subject","plane":"","domain":["Enterprise","HCP"],"industry":["Healthcare provider"],"navPath":"","tags":["EM-HCP-08","W-IND","subject","ClinicalDocument","DocumentSection","Attestation","Amendment","DocumentStatus"],"facets":{}},"whatItIs":"An authored clinical document or record entry, such as a note, a discharge summary or a report, with its author, attestation, status, amendments and medical record retention. Generic document management and terminology are separate contours.","purpose":"Keep clinical documents trustworthy as the legal record of care: who wrote what, when it was signed, and how it was corrected.","scope":{"in":[],"out":[],"boundaries":[]},"distinguishingFeatures":["Signed documents are amended, not edited.","Every document has an author and a status, while attestation is recorded when required for that status and may be absent for drafts or unsigned documents.","Shared versions remain traceable.","Generic document management is a separate contour."],"structure":{"bundles":[{"id":"authorship-and-status","name":"Authorship and status","description":"Who wrote and signed the document.","layers":[{"id":"document-life","name":"Document life","description":"Author, attester and status.","findings":[{"id":"authorship","name":"Authorship","description":"Author, patient, encounter and signature.","questions":[{"text":"Who authored this document, for which patient and encounter?","id":"authorship-q1"},{"text":"Who signed or attested this document, and when?","id":"authorship-q2"}]},{"id":"status","name":"Status","description":"Draft, final, amended or entered in error.","questions":[{"text":"Is this document a draft, final, amended or entered in error?","id":"status-q1"}]}]}]},{"id":"corrections-and-sharing","name":"Corrections and sharing","description":"How the document changed and where it went.","layers":[{"id":"versions","name":"Versions","description":"Amendments, sharing and retention.","findings":[{"id":"amendments","name":"Amendments","description":"Corrections with reasons and authors.","questions":[{"text":"Which amendments were made to this document, by whom and with what reason?","id":"amendments-q1"},{"text":"Which version of this document was valid at a given date?","id":"amendments-q2"}]},{"id":"sharing-and-retention","name":"Sharing and retention","description":"Shared versions, retention and structured content.","questions":[{"text":"With which providers or systems was this document shared, and which version?","id":"sharing-and-retention-q1"},{"text":"Which retention period applies to this document?","id":"sharing-and-retention-q2"},{"text":"Which structured entries are summarized in this document?","id":"sharing-and-retention-q3"}]}]}]}]},"agentConduct":{"may":["Summarize documents for authorized staff with references to the sources.","Flag unsigned documents past a deadline.","Draft documents for clinicians to review and sign."],"mustNot":["Sign or attest documents.","Edit signed documents.","Share documents outside approved exchange channels."],"requiresHuman":["Only the responsible clinician signs or amends clinical documents.","Release of records to third parties follows an approved request process."]},"ethics":{"considerations":["Clinical documents are among the most sensitive personal records.","Drafts produced by tools can carry errors into the legal record if they are not reviewed."],"affectedParties":["Patients","Authoring clinicians","Receiving providers"]},"owners":{"steward":"The head of medical records who answers for the integrity of the medical record.","roles":[],"masterSystems":["Electronic health record system","Clinical document repository","Health information exchange"]},"relations":[{"target":"EM-KNW-01","type":"neighbor"},{"target":"EM-HCP-03","type":"neighbor"},{"target":"EM-HCP-05","type":"neighbor"},{"target":"EM-HCP-07","type":"neighbor"},{"target":"EM-XCT-05","type":"neighbor"},{"target":"EM-XCT-04","type":"neighbor"},{"target":"WM-REC-001","type":"references","note":"conceptual-candidate"},{"target":"WM-REC-002","type":"references","note":"conceptual-candidate"}],"interaction":{"identity":{"applicability":"required","items":["A clinical document has an identifier unique within the repository and a version identifier.","It references one patient record and usually one encounter."]},"properties":{"applicability":"not-applicable","items":[]},"recognition":{"applicability":"required","items":["Records show a document type, author, status and version, with attestation details when present and any unmet attestation requirement visible.","A clinical document must be distinguished from a generic file, a form template and a message."]},"capabilities":{"applicability":"required","items":["The contour supports legal record keeping, document exchange and version history."]},"hazards":{"applicability":"required","items":["Silent edits can hide errors and harm patients.","Sharing the wrong version can mislead other providers."]},"interfaces":{"applicability":"optional","items":["HL7 International publishes the FHIR Composition and DocumentReference resources and the CDA standard.","Integrating the Healthcare Enterprise publishes the XDS profile for cross-enterprise document sharing."]},"context":{"applicability":"required","items":["The contour is used in all care settings that keep a medical record.","Medical record retention follows applicable national and subnational law and other governing obligations, including any applicable preservation holds."]}},"sources":[{"title":"HL7 FHIR: Composition and DocumentReference resources"},{"title":"HL7 CDA and openEHR compositions"},{"title":"IHE XDS: cross-enterprise document sharing"},{"title":"HL7 FHIR R4 Composition resource","url":"https://hl7.org/fhir/R4/composition.html","note":"Checked live (HTTP 200) on 2026-10-21."},{"title":"HL7 FHIR R4 DocumentReference resource","url":"https://hl7.org/fhir/R4/documentreference.html","note":"Checked live (HTTP 200) on 2026-10-21."},{"title":"IHE ITI Technical Framework: Cross-Enterprise Document Sharing (XDS.b)","url":"https://profiles.ihe.net/ITI/TF/Volume1/ch-10.html","note":"Checked live (HTTP 200) on 2026-10-21."}],"openQuestions":["How is an amendment recorded so that the original remains readable?","When does a document become part of the legal medical record?","How are structured entries and narrative text kept consistent?","Settle the boundary and the reuse, extend or new decision against the current specifications.","Confirm the semantic crosswalk, rights and source mastership.","Choose immutable references and run fixture checks before claiming publication readiness."],"resources":{"source":"https://ver.cy/enterprise/models/em-hcp-08/"},"provenance":{"origin":"enterprise research programme","builtFrom":["enterprise/models/em-hcp-08/brief.json","ver-cy/world-models/card-supplements/em-hcp-08.json"],"providers":[],"researchStatus":"published-partial","generatedAt":"","builder":"tools/build_cards.py@1.0.0"},"completeness":{"sections":{"classifiers":"filled","whatItIs":"filled","purpose":"filled","distinguishingFeatures":"filled","structure":"filled","agentConduct":"filled","ethics":"filled","owners":"filled","relations":"filled","interaction.identity":"filled","interaction.properties":"not-applicable","interaction.recognition":"filled","interaction.capabilities":"filled","interaction.hazards":"filled","interaction.interfaces":"filled","interaction.context":"filled","sources":"filled"},"notes":{"interaction.properties":"Enterprise record contour: physical properties belong to referenced world models.","_supplement":"Sections authored in card supplement 1.1.0 by Claude (Opus 5.5) (2026-10-21, unreviewed). Written from the industry contour brief and established practice in the field; source pages were checked live on 2026-10-21. Unreviewed. Revised against an independent Codex review on 2026-10-21.","_gate":"Published through the contour publication gate 1.0 on 2026-10-21T19:02:23+00:00: completeness 1.00; subject: research brief; 3 live sources; review by codex: pass"},"score":1.0}}