A future performance-based statement of objectives (PBSOO) will provide for final development, integration, testing, and implementation of the Document Engine/Dictation Interface for AHLTA. The following, however, is a list of basic requirements that should be incorporated into the project scope to ensure seamless integration into clinical workflow.

Document Engine - User Interface

The Document Engine User Interface should be reconfigured as an AHLTA client module enabling providers to capture and manage documentation, including dictations from commercial transcription vendors.
The Document Engine User Interface module should be adapted to obtain user authentication and privileges from AHLTA, not CHCS.
The Document Engine User Interface module should continue to support review, editing, and saving of drafts. Depending on their privileges, users should be able to forward to staff providers for signature and/or electronically sign and submit the final document into AHLTA.

Dictations

Providers should be able to utilize transcription services and their dictations should be categorized by work type as is the current practice. All outpatient jobs should be stored in AHLTA. All inpatient jobs should be stored in CIS using the Clinicomp HL7 Generic Document Interface. Certain inpatient work types (narrative summaries, consults, and operative reports) should also be stored in AHLTA to ensure access to vital documentation.
Dictations utilizing a work type reserved for confidential material (for example mental health consults) should be stored in AHLTA as a privileged document with “break the glass” requirements for access.
Dictation companies doing business with the MHS will be expected to utilize standard HL7 ADT/Order feeds provided by the Document Engine. Draft transcriptions will be returned to Document Engine which will ensure delivery to the dictating provider for signature. Transcriptions signed by proprietary software will be returned to the Document Engine for delivery directly into the CDR.
Dictations will be filed in AHLTA as either a generic Clinical Note or within the encounter “Add Note” section if the documents relate to a particular visit.

Binary Documents

The Document Engine will also manage binary documentation in addition to text dictations.

It will incorporate a TWAIN compliant scanner interface for capturing paper based information as multi-page TIFF images or pdf documents.
It will allow Windows applications to “print” to the Document Engine using a virtual print driver as a way of capturing documents.
It will intercept legacy medical equipment print jobs and convert them into multi-page TIFF documents using a simple parallel-to-serial port conversion cable.

High Level Technical Overview

The figure below depicts the general architecture in relation to other central projects. It makes extensive use of existing software services, provides a great degree of future flexibility, and enables the MHS to maintain maximal configuration stability, all of which reduce time, effort and cost.

The following diagram illustrates a more detailed proposal for system configuration and workflow. Step one is to ensure that transcription companies are provided accurate demographic AND encounter information. The existing GIS interface within CHCS is thus configured to send a copy of AHLTA HL7 messages to the Document Engine. In addition, the data layer in the local Legacy Gateway Server will be modified to send an HL7 message whenever a new encounter is created. The Document Engine accepts and integrates both these message feeds into standard ADT / Order feeds (which can now include AHLTA encounter information) and retransmits them to vendors delivering documentation for AHLTA.

The transcription companies use these HL7 feeds to return dictations to the Document Engine with all the HL7 metadata required to accurately file them into the appropriate medical record system. Outpatient dictations whose HL7 messages include AHLTA encounter numbers will be filed into the CDR within the encounter “Add Note” section. Dictations without an encounter number will be filed in the Clinical Note section. In either case, the dictation work type will be used as the title of the note to facilitate later search and retrieval; the dictation work types must, therefore, be standardized across the MHS. The filing of a signed dictation by the Document Engine will be accomplished by invoking a new web service exposed on the Legacy Gateway Server; transmission back to the CDR will be handled by the existing long haul infrastructure. Furthermore, existing local cache fail over capabilities can be leveraged. All web service traffic will be SSL encrypted to meet existing security concerns.

All inpatient dictations received by the Document Engine will be submitted upon signature to the Clinicomp HL7 Generic Document Interface for inclusion into CIS. However, dictations work types that are important to the outpatient record (discharge summaries, consults, op reports, etc) will also be sent to AHLTA. Because the Document Engine is an interface AND a workflow engine, all that is needed is some standardization of work types and some simple rules to intelligently handle duplicative inpatient dictation filing. The implications for the quality and completeness of the outpatient medical record are significant.

The diagram also illustrates the configuration for binary documents such as scans or legacy equipment print jobs. In such cases, patient/provider/encounter context is established by the AHLTA client and passed into the Document Engine DOCUCAP, which handles the workflow associated with running a scanner or capturing a print job from a legacy medical device or application. In either case, the end result is a binary pdf or multi-page TIFF image that can be routed, signed, and ultimately submitted for filing using the afore mentioned Legacy Gateway Server web service. The major difference between the workflow for binary documents and text dictations is the way these documents are handled at the CDR. Text documents are small, light weight files easily stored within the CDR proper. Binary files are more akin to digital radiology images and are better stored in a digital asset repository system for obvious performance and scalability reasons. Thus, such potentially massive files will be stored outside the CDR, but linked to the encounter record or patient so that the AHLTA client can retrieve them on demand. Such a storage system is proposed in the AHLTA DFI project; the Document Engine workflow is entirely consistent with the DFI architecture.

Conclusion

Incorporation of the Document Engine into the AHLTA infrastructure will deliver a proven application to the MHS repertoire, adding substantial functionality and flexibility to the desktop client. Civilian transcription companies will be able to interface with AHLTA simply by delivering their payload as HL7 messages to the Document Engine which will provide the user interface for the review, editing, and ultimate submission of dictations. Legacy medical equipment and Windows–based applications will be able to “print” to the Document Engine and have those jobs packaged and delivered to the provider for signature. AHLTA users will be able to control attached scanners in order to incorporate miscellaneous documents using a workflow that is efficient and uninvolved. Finally, the engine is a future-safe universal interface, capable of accepting delivery of patient documentation from virtually any application or data source using message processor plug-ins.

1. Scope

This project will integrate the Document Engine (DE) Government off-the-shelf (GOTS) product into AHLTA and thereby provide an interface for users to import documents from external vendors, other print-capable Windows software, and legacy hardware. It will also allow users to manage unsigned documents through a delegation, review, and signing workflow.

The Document Engine module (DEM) will provide a universal, standard interface for incorporating clinical documents into patient records. Comprehensive information capture is provided from the following:

Clinical text Health Level Seven (HL7) messages,
Print jobs from other Windows applications, and
Print jobs via serial port data from legacy hardware devices.

1.1 Identification

This Software Requirements Specification (SRS) and Interface Requirements Specification (IRS) document applies to the processes and procedures that are employed to develop and test the current fielded version of AHLTA. This document is submitted to fulfill the requirements identified in the Contract Data Requirements List (CDRL) B001 and CDRL B002 as specified in the Statement of Work (SOW) from the Government for this project. Currently, the DE Integration project software is expected to be released as part of Build 844. However, the actual version, release, and build numbers are determined at the time of software delivery and are provided by the Northrop Grumman Information Technology (IT), Health Solutions (hereafter referred to as Northrop Grumman IT) Configuration Manager directly to the Clinical Information Technology Program Office (CITPO) Configuration Manager upon delivery of the software.

1.2 System Overview

1.2.1 General Nature of System

Figure 1-1 below illustrates the proposed integration plan for the GOTS DE system and its components. The DE system consists of a main Document Engine Server (DES), two database schemas to be located in the In-line Cache Database (ICD) on the Local Cache Server (LCS), an applet, and a Windows virtual print driver to be installed on each AHLTA Client Workstation. Dotted lines indicate where components or functionality will be implemented, while solid lines indicate current components or functionality.

Figure 1‑1: Proposed DE System Components

The DEM will provide a user interface link to enable users to add various documents to an encounter or patient record. The DE system consists of the following software components:

Oracle HyperText Transfer Protocol (HTTP) Server: a component of the Oracle 10g Application Server handling HTTP web traffic to/from the DE application, DE Web Services, and LCS Web Services.
DE Application: a Java web application running in an Oracle Containers for Java 2 Enterprise Edition (J2EE) (OC4J) instance of the Oracle Application Server 10g on the DES.
DE Web Services: a set of Web Services on the DES providing data layer access to the DE database.
Java Database Connectivity (JDBC): database driver and Application Programming Interfaces (APIs), providing connection and Structured Query Language (SQL) commands to access Oracle database.
System Print Services: a set of software utilities, Operating System dependent, providing print capabilities to any network printers recognized by DES.
HL7 Engine: a component of the Oracle Integration Business-to-Business (B2B) providing clinical data exchange using the HL7 standard.
DE Database: persistent storage for all documents and metadata collected by the DE application. The DE application will be using these services to handle operations such as patient search, clinic search, provider search, and encounter information.
Generic Interface Engine (IE): a set of Web Services on the Generic Interface providing data layer access to the Clinical Data Repository (CDR). The DE application will be using these services to store signed Clinical Notes.
HL7 Database: persistent storage for all incoming and outgoing HL7 messages; used by the Oracle Business Integration Healthcare Adapter.
LCS Web Services: a set of Web Services on the LCS providing data layer access to CDR data.
Document Capture Driver: a redirection port monitor driver installed on the AHLTA Client Workstation. This driver redirects a special printer port output to the Document Capture Applet.
Document Capture Applet: a Java applet installed on the AHLTA client workstation that provides the mechanism for data capture from legacy hardware devices and the Windows virtual printer.

Questions have been raised as to whether the DE application and its components could be deployed within the existing LCS to eliminate the need for a new hardware asset. The DE will involve significant data streaming from the Document Capture module and significant inbound/outbound HL7 traffic from the CDR and Transcription System (TS) to the HL7 engine.

Given the critical nature of LCS performance, which could be compromised by server load from the DE, it is recommended that the DE application and components use dedicated servers. This document will assume that the DE will run on a new server to be added to the baseline AHLTA/Military Treatment Facility (MTF) hardware. Its operations are dependent on the LCS; hence, both servers must be deployed together.

Both the LCS and DES are expected to reside inside the MTF network boundary. The TS may or may not be housed within the facility’s firewall.

1.2.2 History of Development, Operation, and Maintenance

AHLTA broadly provides views of a patient’s medical history and documentation tools for that history and for clinical encounters (visits) in the outpatient environment.

This AHLTA enhancement will facilitate the storage and retrieval of imported medical documents, making them accessible to other authorized AHLTA users. DE helps facilitate the completeness of the electronic medical record and the subsequent inclusion of these documents in AHLTA. It also leverages existing systems to maximize the productivity of Military Health System (MHS) specialty providers.

1.2.3 Project Sponsor, Acquirer, User, and Support Agencies

CITPO is the project sponsor and acquiring organization. The users are the uniformed, medical professionals of the Navy, Army, and Air Force Services. The support agencies consist of the Tri-Service Infrastructure Management Program Office (TIMPO), who supplies the network infrastructure, and the Defense Information Systems Agency (DISA), who supplies the housing and maintenance of the computer networks and the CDR.

1.2.4 Current and Planned Operating Sites

When this project is planned for fielding, all sites planned for the rollout of AHLTA will receive the ability to utilize this enhanced capability. There will be a beta testing period for this local caching capability with a selected subset of sites that will be determined.

1.2.5 Other Relevant Documents

All relevant documents for this project are identified in Section 2.

1.3 Assumptions and Dependencies

While providing AHLTA the capability for interfacing with third-party systems, such the TS, this project does not specifically implement any interfaces with third-party systems.
The GOTS DE is being integrated largely as-is. Enhancement recommendations to the developers of this product have been made. However, it is not the intent of this project to specify the details of the design of this product. Rather, the intent of this project is to specify and implement the integration of this product into AHLTA.
It is assumed that the GOTS DE will fully support the HL7 v2.4 eXtensible Markup Language (XML) standard for communications to the transcription vendors.
Third-party products and vendors must have the capacity to export documents in the HL7 v2.4 standard format, per CITPO technical guidance.
Third-party products and vendors must identify the following information to associate with new medical documents:
- The provider’s name and identification (ID) number,
- The patient’s name and ID number,
- The AHLTA appointment Internal Entry Number (IEN) (if the transcribed documentation is associated with a scheduled appointment),
- The date of the dictated report, and
- The type of note being dictated.
- Providers reviewing newly transcribed documents on AHLTA will be responsible for verifying that the content of the report is associated with the correct online patient record prior to signing and releasing the document.
- There are no new or alterations to existing reporting requirements for this project.
- There is no additional AHLTA audit logging required for this project.
- There are no new alterations to existing Operational Requirements Document (ORD) timing requirements for this project.
- There are no new or alterations to existing performance monitoring (Application Response Measurement [ARM]) requirements for this project.
- There are no impacts to existing requirements for this project.

1.4 Document Overview

The purpose of this document is to provide the Government with a thorough understanding of the requirements and expected interfaces for the DE Integration project as it relates to AHLTA. The document is organized as follows:

Section 1 describes the scope of the project and includes an overview of the system and an overview of the document structure.

Section 2 identifies related referenced documentation.

Section 3 provides an overview of the requirements.

Section 4 describes Qualification Provisions, if they apply to the project.

Section 5 explains the details of the Requirements Traceability Matrix (RTM).

Section 6 contains the list of acronyms used in the document.

Appendix A contains the system requirements for this project.

This document is intended for use by CITPO, Government, and contract personnel only. Any other use, duplication, or distribution of this document without the express written consent of CITPO is strictly forbidden. Requests for use of this document can be made to the CITPO Task Manager as identified in the SOW for this project listed in Section 2.

2. Referenced Documents

"CITPO System Enhancements" SOW, Delivery Order (DO) B303, 30 September 2005.

Document Engine Integration Draft Software Requirements Specification and Interface Requirements Specification, Version 1.0, 11 July 2006.

3. Requirements

3.1 Required States and Modes

3.1.1 Provider Graphical User Interface (PGUI) Mode Requirements

PGUI will not be supported by the Department of Defense (DoD) by the time this functionality is released (expected support end date is 30 September 2006).

3.1.2 Composite Health Care System II (CHCS II)-Theater Mode Requirements

This feature set is not available in, nor is it currently thought to be applicable to CHCS II-Theater mode.

3.1.3 AHLTA Mode Requirements

As the primary mode targeted for this project, this functionality will be enabled in AHLTA Normal mode.

3.1.4 Block 2 (Spectacle Request Transmission System II [SRTS II], Dental) Impact

This functionality has no impact on Block 2 features.

3.1.5 Local Cache (Failover Mode) Requirements

This functionality will not be available in Failover mode.

3.1.6 Training Mode Requirements

This functionality will not be available in the Training System.

3.2 Computer Software Configuration Item (CSCI) Capability Requirements

3.2.1 Major Functions Overview

There are several key workflows involved with regard to the DE as integrated into AHLTA. These workflows are described in Section 3.2.2.

Further, there are two GOTS DE user interface components being integrated into the applications: the Clinical Data Capture module (CDCM) and the Documents Inbox module (DIM). The CDCM is the primary document capture interface, while the DIM is the primary interface for reviewing, editing, delegating, and signing documents. These are described in the subsequent sections.

Pertinent interfaces being introduced into the AHLTA environment with this project are discussed in Sections 3.3 and 3.4.

See Appendix B for a listing of the Functional Requirements associated with this project.

3.2.2 Workflow Scenarios

This section describes the workflow scenarios enabled by the integration of the DE, including significant technical details.

3.2.2.1 TS and DEM

The following workflow diagrams describe the interactions between the text from a notional TS and the DEM.

3.2.2.1.1 Patient Visit Notification

When a patient books an appointment at a clinic, the DEM will send a Visit Notification message including the appointment ID to the TS. When a patient admits to an MTF, the DEM will send a Visit Notification message including the Admission Number to the TS.

Figure 3‑1: HL7 Workflow

3.2.2.1.2 Dictation Processing

After examining a patient, either at a clinic or hospital ward, the provider accesses the TS and dictates a note for the visit. If the patient was seen at a clinic and has an encounter, the provider is expected to include the Appointment ID associated with the encounter as part of the dictation. The TS validates the patient first by PatientIEN + Facility Numeric Concept ID (NCID) (preferred when available) and then Name and Family Member Prefix (FMP)/Social Security Number (SSN).

After the dictation is transcribed, TS sends the transcribed document to DEM via an HL7 message. DEM checks the validity of the patient and dictating provider. If either check is unsuccessful, the TS will be informed of the error. If both patient and provider are valid, DEM will accept the transcribed dictation document.

DEM then checks to see if an appointment ID is included with the document. If it is, then DEM will query AHLTA for encounter information associated with this appointment ID and use it to associate with this document. If no encounter information is available, DEM will disregard this appointment ID and will not associate the document with an encounter. The document is then stored in the DE database.

Figure 3‑2: Dictation Workflow

3.2.2.2 CDCM

The CDCM can receive documents from third-party Windows applications and hardware medical devices that provide TWAIN-compliant output. The following workflow diagrams describe these interactions.

3.2.2.2.1 Print Capture

The Print Capture Workflow diagram illustrates how a Windows application running a Pulmonary Function Test (PFT) can send its results to the CDCM.

Figure 3‑3: Print Capture Workflow

3.2.2.2.2 Device Capture

The Device Capture Workflow diagram illustrates how an Electrocardiogram (EKG) machine can send its results to the CDCM.

Figure 3‑4: Device Capture Workflow

3.2.2.3 Back End Processes

3.2.2.3.1 Documents Inbox Process

Figure 3‑5: Documents Inbox Process

3.2.2.3.2 AHLTA Process

Figure 3‑6: AHLTA Process

3.2.3 CDCM

The CDCM is a GOTS DE user interface module that will be used to capture external documents through several mechanisms. The module will reside in the Tools folder under the Desktop node. The AHLTA client will be configured to have a new Clinical Data Capture link called to represent this new module.

When the CDCM is activated, the AHLTA client will create a web container in which to render the module. User context is required for this module. If no patient is available when this module is invoked, the user will be required to identify an appropriate patient before the document/data can be captured. If an encounter has been selected, this will also be passed to the DE. When the AHLTA patient or encounter context changes (e.g., user selects a different patient), the new context will be passed to the DEM when it is reactivated.

Two panels, Clinical Data Capture and Documents Inbox, will be rendered by default (see Figure 3‑7). The Clinical Data Capture panel will capture external documents (in addition to dictations) or data through the following mechanisms:

Windows print jobs capture documents and/or electronic images produced by Windows applications.
Device print jobs capture print output from legacy hardware (e.g., Vesticular equipment, EKG machine).

The Documents Inbox panel, part of the CDCM, is included to provide a convenient shortcut for the user to access the newly captured document/data for further processing without having to leave the CDCM. The user can toggle this panel out of view by clicking on the Capture Only View button in the Note Data tab of the Clinical Data Capture panel. Afterwards, the label of this button changes to “Capture/Inbox View,” and clicking on this button will bring the Documents Inbox panel back into view.

3.2.3.1 Clinical Data Capture Panel

The Clinical Data Capture panel is used to import external documents or data into the DE.

Two tabs, Note Data and User Settings, are available on the Clinical Data Capture panel.

Use to toggle this panel in/out of view

Use to trigger CDCM

“Documents Inbox” Panel

“Clinical Data Capture” Panel

Figure 3‑7: CDCM

Figure 3‑8: Error Message Displayed When Required Metadata is Missing

Table 3‑1: Clinical Data Capture Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-116	When an authorized user accesses the "Clinical Data Capture" module, the system shall display the Clinical Data Capture panel in the left side of the workspace and the Provider Documents Inbox panel in the right side of the workspace. Clarification: access to the module from the folder tree menu and the Go menu and the toolbar if selected as a module to display. Business Rule: This requires Read, Write access to the DOCUMENT_CAPTURE security object in the Security Matrix.	Applicable	Not Applicable	Not Applicable
New DE-118	The system shall allow the user to hide the Provider Documents Inbox by clicking the "Capture Only View" button located on the Note Data tab of the Clinical Data Capture panel.	Applicable	Not Applicable	Not Applicable
New DE-119	The system shall allow the user to restore the display of the Provider Documents Inbox by clicking the "Capture/Inbox View" button from the Clinical Data Capture Panel when only the Clinical Data Capture Panel is displayed.	Applicable	Not Applicable	Not Applicable
New DE-164	The system shall allow the user to select the capture option by selecting the "Windows Application" radio button on the Note Data tab of the Clinical Data Capture Module. Business rule: The user should select "Windows Application" if the to-be-captured document or data comes from an application residing on the same workstation as the AHLTA client.	Applicable	Not Applicable	Not Applicable
New DE-164-3	The system shall allow the user to select the capture option by selecting the "Serial Port Connected Device" radio button on the Note Data tab of the Clinical Data Capture Module. Business rule: "Serial Port Connected Device" option should be selected if the document/data is coming from a medical device connected to the serial port of the workstation running the AHLTA client.
New DE-164-1	Upon the user selecting the “Begin Capture” button on the Note Data tab of the Clinical Data Capture Module, the system shall display an error message if any required document metadata is not entered. Clarification: The system will display the message “Required data missing.” When the user clicks OK they will be returned to the Note Data tab.	Applicable	Not Applicable	Not Applicable
New DE-164-4	Upon returning to the Note Data tab of the Clinical Data Capture Module from a “required data missing” error message, the system shall display as visually distinct the required field(s) causing the error message.
New DE-182	The system shall set the Clinical Data Capture module document size default to maximum size limit of 500K compressed file limit size for imported documents. Clarification: This is due to the 500K compressed file limit for importing documents into the Clinical Notes module.	Applicable	Not Applicable	Not Applicable
New DE-182-1	When the user selects the Submit button from the Clinical Data Capture screen, the system shall display an error message if the size exceeds maximum size limit of 500K. Clarification: The user will select from the options displayed in the message below: <<...OLE_Obj...>> a. Store in DE: Document is signed and kept in user's DE inbox with status of "SIGNED". User is then returned to the Note Data screen. b. Print: Document is signed and user can obtain a printed copy to add it to patient's paper charts. User is then returned to Note Data screen. Document will be purged and not saved in DE. c. Cancel: Document will not be signed -- it will be purged -- and user is returned to Note Data screen.

3.2.3.1.1 Note Data Tab

The Note Data tab allows the user to append metadata to the document being submitted. By default, this tab is selected when the CDCM is activated. This tab will be prepopulated with contextual information obtained from the current user context as well as settings configured via the User Settings tab.

Use for Patient selection

“Calendar” icon

Use to initiate document capture operation

Capture Action Controls Section

“Provider Search” icon

“Clinic Search” icon

Reset all “editable” fields to default values

Figure 3‑9: Note Data Tab

The Note Data tab is divided into four sections:

Document Information section: This section provides the user with the means to supply metadata regarding the document/data to be captured, including the following:
- Add to Patient Chart (required/editable): This displays the name of the patient with which the new document/data will be associated. If a patient is currently selected in the AHLTA client, the text box will be prepopulated with the patient name; otherwise, “No Patient Selected” will be displayed by default. The format of this field is “<Last name>,<First name> <Middle>” (e.g., “ZZTEST,ADAM G”).
  - Change Patient button: This button activates a patient search box where the user will be able to perform a patient search (see Figure 3‑11) with the following information:

Patient’s last name: Last name of patient (case-insensitive, required; two-character minimum).

Patient’s first name: First name of patient (case-insensitive, optional). This search field can only be used in conjunction with the Last Name field.

Original Date of Document (required/editable): This text box displays the date/time that the clinical data is captured and defaults to the current workstation date/time. A calendar icon is available to facilitate date change.
Author (required): The name of the current user is displayed in this text box. This field is set by the system and cannot be changed.
Note Type (required/editable): This field displays the type of document or data. The user can select from a list of note types, configurable by MTF. If set, the note type selected in the User Settings tab will be displayed by default.
Specialty (required/editable): This is definable by MTF based on the kind of cares/specialties at each site. If set, the specialty configured in the User Settings tab will be displayed by default.
Note Title (optional/editable): This text box allows a user can enter a short description of the document or data, if desired. If set, the default note title configured in the User Settings tab will be displayed. The drop-down menu represents a collection of titles previously used by this user, stored as part of the user preferences cache. The last five titles used by the user will be cached as user preferences and displayed for selection when the drop-down menu arrow in the text box is selected.
Data Delivery Controls section: This section allows the user to specify actions to take on incoming documents or data.
- Document Delivery options: The user must select one of the following options via radio buttons:
  - My Inbox (selected by default): When selected, the incoming document/data will be submitted to the current user’s Documents Inbox for further processing.
  - Auto-Sign & Submit Document: When selected, DE will automatically sign the incoming document/data and submit it to the CDR for filing. This option is only available for users with signature authority.
  - Forward Document: When selected, the DE will forward the incoming document/data to the specified provider’s Documents Inbox. If a provider is specified in the User Settings tab, the field will be prepopulated. Additionally, if the user does not have a provider default set, the system shall enable the user to use the provider search option (see Figure 3‑12).
Associate Clinic (optional/editable): If encounter context is available when CDCM is called, the Associate Clinic text box will be prepopulated with the clinic linked to the selected encounter. This field will be blank if no encounter is selected.
- The user can use the Clinic Search icon to prompt the system to display the Clinic Search screen, where the user will be able to select an appropriate clinic.

NOTE: This is new metadata for DE. It is added to be consistent with the metadata collected by the Document, File, and Image (DFI) screen (see Figure 3‑13).

Document Content section: This section allows user to add supplemental descriptions of the incoming document or data.
- Note Text Area: The user can enter free text in this field to provide a more detailed description of the document/data to be captured.
- Formatting: A number of formatting functions are available, including Font, Font Size, Bold, Italic, Underline, Align Left, Align Right, and Center.
- Print Capture Action Controls section: This section allows a user to select the document capture type and to initiate capture. Two document capture options are available:
  - Windows Application—This option captures print data from Windows applications residing on the same workstation as the AHLTA client.
  - Serial Port Connected Device—This option captures print data from external hardware connected to the serial port of the workstation running the AHLTA client as shown below.

Figure 3‑10: Serial Connected Device Print Flow

The Begin Capture button initializes a Windows Virtual Printer driver for document/data capture using the capture option selected above. Document/data captured by this module will be stored in the DE.

The Reset Form for New Document(s) button resets all editable fields on this panel.

Table 3‑2: Note Data Tab Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-114	The system shall display the "Note Data" and "User Settings" tabs when the Clinical Data Panel of the Clinical Data Capture Module is accessed..	Applicable	Not Applicable	Not Applicable
New DE-117	The system shall display the "Note Data" tab as the default tab when displaying the Clinical Data Capture panel of the Clinical Data Capture Module.	Applicable	Not Applicable	Not Applicable
New DE-117-1	The system shall display the Note Data tab of the Clinical Data Capture Panel in 4 sections, Document Information, Data Delivery Controls, Document Content, and Print Capture Choices.	Applicable	Not Applicable	Not Applicable
New DE-121	The system shall populate the Document Information on the Note Data tab of the Clinical Data Capture panel with the patient's Last Name, First Name, Middle Initial. Clarification: Patient name will be populated if a patient is loaded in AHLTA, otherwise “No patient selected” will be displayed.	Applicable	Not Applicable	Not Applicable
New DE-121-3	The system shall populate Author field on the Document Information on the Note Data tab of the Clinical Data Capture panel with name of the logged in user.	Applicable	Not Applicable	Not Applicable
New DE-121-1	The system shall display the following fields in the Document Information section of the Note Data tab: Add to Patient Chart, Original Date of Document, Author, Note Type, Specialty, and Note Title.	Applicable	Not Applicable	Not Applicable
New DE-131	The system shall default the "Original Date of Document" field in the Document Information section of the "Note Data" tab of the Clinical Data Capture Panel, to current workstation date/time. Clarification: This field is required and editable.	Applicable	Not Applicable	Not Applicable
New DE-121-2	The system shall default the Add to Patient Chart field to the patient selected in AHLTA.	Applicable	Not Applicable	Not Applicable
New DE-250	The system shall require the user to enter a Provider in the "To" field when "Forward Document" is selected.	Applicable	Not Applicable	Not Applicable
New DE-162	The system shall allow the user to enter an explanation of the incoming document/data in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module. Clarification: This field size is unlimited because it is stored as a CLOB in the Oracle database. CLOBs allow unlimited number of characters.	Applicable	Not Applicable	Not Applicable
New DE-163	The system shall allow the user to format the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module by selecting from the options available in the formatting tool area of the "Document Content" section. Clarification: The user can select the font type, font size, attributes (bold, italic, underline), and justification (left, right, centered) in the formatting tool area.	Applicable	Not Applicable	Not Applicable
New DE-163-1	The system shall allow the user to select the font type attribute for the note explanation by selecting from the drop down list of fonts available in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-2	The system shall allow the user to select the font size attribute for the note explanation by selecting from the drop down list of font sizes available in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-3	The system shall allow the user to select the bold font attribute for the note explanation by selecting the “bold” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-4	The system shall allow the user to select the italic font attribute for the note explanation by selecting the “italic” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-5	The system shall allow the user to select the underline font attribute for the note explanation by selecting the “underline” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-6	The system shall allow the user to left-justify the note explanation by selecting the “left-justify” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-7	The system shall allow the user to right-justify the note explanation by selecting the “right-justify” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-163-8	The system shall allow the user to center the note explanation by selecting the “center” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-164-2	Upon returning to the Note Data tab from a “required data missing” error message, the system shall position the cursor focus in the required field causing the error message. Clarification: Error message states: Required data missing.	Applicable	Not Applicable	Not Applicable
New DE-166	When the user selects the "Reset Form For New Document(s)" button the system shall reset all editable fields on the Note Data tab of the Clinical Data Capture Panel of the Clinical Data Capture module to the User Settings defaults if any were set by the user on the User Settings tab, otherwise resets to system defaults.	Applicable	Not Applicable	Not Applicable
New DE-179	If the user selects the "Forward Document" delivery option, the system shall display the submitted document as a new entry in the Documents Inbox Panel of the Provider designated in the “To” field in the Data Delivery Controls section of the “Note Data” Tab.	Applicable	Not Applicable	Not Applicable
New DE-132	The system shall display a "Calendar" icon beside the "Original Date of Document" field to allow the user to make desired date changes. Clarification: Clicking the Calendar icon will display the standard calendar feature.	Applicable	Not Applicable	Not Applicable
New DE-133	The system shall display the name of the current logged in user in the "Author" field in the Document Information section of the "Note Data" tab on Clinical Data Capture Panel of the Clinical Data Capture module. Clarification: This field is required and is set by the system and cannot be changed. Maximum of 50 characters.	Applicable	Not Applicable	Not Applicable
New DE-134	The system shall display a drop-down list of note types when the user selects the arrow next to the "Note Type" field in the Document Information section of the "Note Data" tab of the Clinical Data Capture Panel of the Clinical Data Capture module. Clarification: This field is required. The user can set a Note Type in the "User Settings" tab that will display by default, otherwise the default display is blank.	Applicable	Not Applicable	Not Applicable
New DE-136	The system shall display a drop-down list of care types/specialties when the user selects the arrow next to the "Specialty" field in the Document Information section of the "Note Data" tab of the Clinical Data Capture Panel of the Clinical Data Capture module. Clarification: This field is required and editable. The user can set a default Specialty to display in the Specialty field from the "User Settings" tab, otherwise the default display is blank. Maximum 50 characters.	Applicable	Not Applicable	Not Applicable
New DE-138	The system shall allow the user to enter a short description of the document or data in the "Note Title" field of the Document Information section of the "Note Data" tab of the Clinical Data Capture Panel of the Clinical Data Capture module. Clarification: This field is optional and editable. The user can set a default to display in "Note Title" from the "User Settings" tab, otherwise the default display is blank. Maximum 80 characters.	Applicable	Not Applicable	Not Applicable
New DE-138-1	The system shall allow the user to select from a list of previously used Note Titles from the drop-down list in the Note Title field. Clarification: list displays the last 5 titles used by the user.	Applicable	Not Applicable	Not Applicable
New DE-139	As part of the user's preferences cache, the system shall store the last 5 Note Titles previously used by the user and display them in the Note Titles drop-down list.	Applicable	Not Applicable	Not Applicable
New DE-142	The system shall allow the user to choose one of three delivery options, "My Inbox", "Auto-Sign & Submit Document", and "Forward Document" in Document Delivery Controls section of the Note Data tab of the Clinical Data Capture Panel for incoming documents/data. Clarification: This selection is required. “Auto-Sign & Submit Document” is only available if the provider has signature authority (security object privilege “Current_encounter” = “C” (Can sign)). The "Auto-Sign & Submit Document" option will be disabled if the user does not have signature authority.	Applicable	Not Applicable	Not Applicable
New DE-143	The system default for "Document Delivery Option" in the Document Delivery Controls section of the Clinical Data Capture Panel of the Clinical Data Capture module shall be "My Inbox". Clarification: The radio button beside My Inbox will always be selected as the default unless the user has designated another option as default on the "User Settings" tab.	Applicable	Not Applicable	Not Applicable
New DE-144	The system shall allow the user to automatically sign the incoming document/data and submit it to CDR for filing by selecting the "Auto-Sign & Submit Document" delivery option in the Data Delivery Controls section of the Clinical Data Capture Panel. Clarification: “Auto-Sign & Submit Document” is only available if the provider has signature authority (security object privilege “Current_encounter” = “C” (Can sign)). This option will be unavailable (disabled/grayed out) to users who do not have signature authority.	Applicable	Not Applicable	Not Applicable

3.2.3.1.2 Patient Search

On the Patient Search box, the user will be able to perform a patient search using the following criteria:

Patient’s last name: Last name of patient (case-insensitive, required; two-character minimum).
Patient’s first name: First name of patient (case-insensitive, optional). This search field can only be used in conjunction with the Last Name field.

The system will initiate the search based on search criteria supplied when the Find button is selected. The New Search button is used to reset current search criteria.

The system will display results matching the search criteria as shown in the Search Results section of Figure 3‑11. At a minimum, the following patient metadata will be displayed:

Name: Full name of patient,
FMP/Sponsor SSN: Patient’s FMP and SSN of sponsor,
Gender: Patient’s gender, and
Date of Birth: Patient’s birth date.

To select a patient, the user must select the checkbox associated with the desired patient prior to selecting the OK button. The system will return the user to the Note Data tab and populate the Add to Patient Chart field with the newly selected patient. The user can also return to the Note Data tab without selecting a patient using the Cancel button.

Search Criteria

Search Results

Use to reset search criteria

Use to initiate search

Indicates a patient is selected

User requesting patient replacement

User cancels patient replacement operation

Figure 3‑11: Patient Search/Selection Box

Table 3‑3: Patient Search Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-110	If no patient is is loaded on the workstation when the user selects the Clinical Data Capture module, the system shall display "No Patient Selected" in the Add to Patient Chart field of the Note Data tab.	Applicable	Not Applicable	Not Applicable
New DE-122	The system shall require a patient name in the "Add to Patient Chart" field in the Document Information section of the Clinical Data Capture Panel. Clarification: This field is required and editable. Shall display as <Last Name>,<First Name> <Middle Initial> (i.e. “ZZTEST,ADAM G”)	Applicable	Not Applicable	Not Applicable
New DE-123	The system shall allow a user to change the patient name in the Add to Patient Chart field on the Note Data tab of the Clinical Data Capture panel by clicking the "Change Patient" button.	Applicable	Not Applicable	Not Applicable
New DE-124	When the user selects "Change Patient" from the "Note Data" tab of the Clinical Data Capture panel of the Clinical Data Capture module the system shall display the Document Engine "Patient Search" box.	Applicable	Not Applicable	Not Applicable
New DE-125	The system shall allow the user to search AHLTA for a patient by last name, first name, in the "Patient Search" box. Clarification: 2 character minimum. Last Name is required. First Name is optional and must be used only in conjunction with the Last Name.	Applicable	Not Applicable	Not Applicable
New DE-126	When the user clicks "Find" on the Patient Search box the system shall display the number of patients found and the results of the search in the Patients found section of the Patient Search box.	Applicable	Not Applicable	Not Applicable
New DE-126-1	The system shall display the following data with each search result returned on the Patient Search box: Patient full name, FMP/Sponsor’s SSN, Gender and Date of Birth.	Applicable	Not Applicable	Not Applicable
New DE-127	The system shall allow the user to select a patient from the search results by clicking the checkbox beside the desired patient.	Applicable	Not Applicable	Not Applicable
New DE-128	When the user has selected a patient from the search results displayed on the Patient Search box and clicks "OK", the system shall return the user to the "Note Data" tab and display the selected patient's name (last name, first name, middle initial) in the "Add to Patient Chart" field in the Document Information section of the "Note Data" tab of the "Clinical Data Capture" Panel. Clarification: User can select one patient only.	Applicable	Not Applicable	Not Applicable
New DE-129	The system shall allow the user to return to the "Note Data" tab by clicking "Cancel" from the bottom of the Patient Search box. Clarification: If user selects Cancel, no changes will be made to the Patient field.	Applicable	Not Applicable	Not Applicable
New DE-130	The system shall allow the user to reset the search criteria on the Patient Search box by clicking "New Search". Clarification: Clicking the "New Search" button will clear the Last Name and First Name fields and the search results allowing the user to enter new search criteria.	Applicable	Not Applicable	Not Applicable
New DE-130-1	If a patient is loaded in AHLTA and the user selects a different patient on the Note Data tab, the system shall load the newly selected patient in AHLTA.	Applicable	Not Applicable	Not Applicable

3.2.3.1.3 Provider Search Screen

A Provider Search screen (Figure 3‑12) will be displayed to allow the user to perform a provider search after providing the following information:

Provider name: Full or partial name of provider (case-insensitive). A minimum of two characters must be entered.

When the Find button is selected, the system will initiate the search based on search criteria supplied and the facility that is associated with the current user’s session. The New Search button is used to reset current search criteria.

The system will display the following metadata for each provider returned from the search:

Provider Name: Full name of provider in the format of “<Last name>,<First name> <Middle>”.
Clinic: Full name of clinic.

To select a provider, the user must select the checkbox associated with the desired provider prior to selecting the OK button. The system will return the user to the Editor tab where the To text box will be populated with the name of the selected provider.

The system will allow the user to use the Cancel button to exit the screen without selecting a provider.

Figure 3‑12: Provider Search/Selection Box

Table 3‑4: Provider Search Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-145	The system shall allow the user to automatically forward the incoming document/data to another provider's Documents Inbox by selecting the "Forward Document" radio button in the Document Delivery Controls section of the Clinical Data Capture Panel. Clarification: By default this option is not selected.	Applicable	Not Applicable	Not Applicable
New DE-147	The system shall allow the user to search for a Provider by clicking the Provider search icon which will display the Provider Search screen. Business rule: User will be required to select a provider to forward the document to using the “Provider Search” icon. This field is blank unless the user has pre-set using the “User Settings” Tab.	Applicable	Not Applicable	Not Applicable
New DE-147-1	The system shall allow the user the ability to search for a provider by provider name from the Provider Search. Clarification: a minimum of 2 characters must be entered. The format is Last name, First name	Applicable	Not Applicable	Not Applicable
New DE-147-2	Upon the user entering the search criteria in the Provider Name field and selecting the “Find” button on the Provider Search screen, the system shall display the the number of results found and search results in the Provider Found section.	Applicable	Not Applicable	Not Applicable
New DE-147-3	The system shall display search results on the Provider Search screen based on the search criteria entered in the Provider Name field and the MTF the user is logged into.	Applicable	Not Applicable	Not Applicable
New DE-147-4	The system shall display the following metadata for each provider returned in the provider search on the Provider Search screen: Provider Name and Clinic	Applicable	Not Applicable	Not Applicable
New DE-147-5	The system shall allow the user to select a provider from the Provider Search screen by selecting the checkbox next to the provider name. Clarification: By selecting the checkbox, the system places a checkmark in the checkbox indicating the provider is selected.	Applicable	Not Applicable	Not Applicable
New DE-147-7	When the user has selected a provider from the search results displayed on the Provider Search box and clicks "OK", the system shall close the Provider Search box, return the user to the "Note Data" tab and display the selected provider’s name (last name, first name) in the "To:" field in the Data Delivery Controls section of the "Note Data" tab of the "Clinical Data Capture" Panel. Clarification: User can select one provider only.	Applicable	Not Applicable	Not Applicable
New DE-147-8	The system shall allow the user to return to the "Note Data" tab by clicking "Cancel" from the bottom of the Provider Search box.	Applicable	Not Applicable	Not Applicable
New DE-147-6	The system shall clear the Provider Name field and search results on the Provider Search screen upon the user selecting the New Search button.	Applicable	Not Applicable	Not Applicable

3.2.3.1.4 Clinic Search Screen

The user will be able to search for a clinic by clicking on the Clinic Search icon to the right of the Associate Clinic text box. A Clinic Search screen (Figure 3‑13) will be displayed to allow the user to perform a clinic search based on the following information:

Clinic name: Full or partial name of clinic (case-insensitive). A minimum of two characters must be entered.

The system will initiate the search based on search criteria supplied and the current facility that is associated with the current user’s session when the Find button is pressed. The New Search button is used to reset current search criteria.

The system will display the following metadata for each clinic returned from the search:

Clinic: Full name of clinic.

To select a clinic, the user must select the checkbox associated with the desired clinic prior to selecting the OK button. The system will return the user to the Editor tab where the Associate Clinic text box will be populated with the name of the selected clinic.

The user can also use the Cancel button to exit the screen without selecting a clinic.

Figure 3‑13: Clinic Search/Selection Box

Table 3‑5: Clinic Search Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-151	If an encounter is open on the workstation when the Clinical Data Capture module is accessed, the system shall pre-fill the "Associated Clinic" text box in the Document Delivery Controls section of the Clinical Data Capture Panel with the clinic linked to the selected encounter. Clarification: This field will be blank if no encounter is selected.	Applicable	Not Applicable	Not Applicable
New DE-151-1	If no encounter is open on the workstation when the Clinical Data Capture module is accessed, the system shall display the Associate Clinic field as blank.	Applicable	Not Applicable	Not Applicable
New DE-152	The system shall display the Clinic Search box when the user selects the "Clinic Search" icon next to the Associate Clinic text box in the Document Delivery Controls section of Note Data tab on the Clinical Data Capture Panel.	Applicable	Not Applicable	Not Applicable
New DE-155	In the Clinic Search box, the system shall allow the user to enter a full or partial Clinic Name and then select the "Find" button.	Applicable	Not Applicable	Not Applicable
New DE-156	The system shall allow the user to clear the search field and search results in Clinic Search box by selecting the "New Search" button.	Applicable	Not Applicable	Not Applicable
New DE-157	When the user selects the "Find" button, the system shall return a list for the MTF displaying the number of clinics found and the Clinic Name in the "Clinics Found" section at the bottom of the "Clinic Search" box.	Applicable	Not Applicable	Not Applicable
New DE-158	The system shall allow the user to select a clinic from the "Clinics Found" list by checking the "Select" checkbox and selecting "OK".	Applicable	Not Applicable	Not Applicable
New DE-161	The system shall close the Clinic Search box and display the name of the selected clinic in the "Associate Clinic" text box in the Document Delivery Controls section on the Note Data tab of the Clinical Data Capture module when the user clicks "OK" from the Clinic Search box.	Applicable	Not Applicable	Not Applicable
New DE-161-1	The system shall allow the user to return to the "Note Data" tab without selecting a clinic by clicking "Cancel" from the bottom of the Clinic Search box.	Applicable	Not Applicable	Not Applicable

3.2.3.1.5 Print Capture Operation—Windows Application

When the Begin Capture button is activated with the Print Capture option “Windows Application” selected, a Windows Print screen is displayed and the Clinical Data Capture driver will begin to monitor for any print job coming into the Clinical Data Virtual Printer (see Figure 3‑14). The Submit Document button will be disabled until a document has been successfully captured.

The label on the Submit Document button will be assigned dynamically depending on what was previously selected for the delivery option on the Note Data tab. The three different labels are illustrated in Figure 3-15.

Indicator that Windows Virtual Printer driver is waiting to receive a print job

Figure 3‑14: Clinical Data Virtual Printer (Windows Application)

Delivery Option Selected on the Note Data Tab	[Submit Button Label]

Figure 3‑15: Submit Button Dynamic Label

When a print job to this printer is initiated by a third-party application (see Figure 3‑16), the Clinical Data Capture driver will capture all incoming PostScript data, convert it into Portable Document Format (PDF) or Tagged Image File Format (TIFF) (depending on the driver configuration), and allow the user to preview the document as shown in Figure 3‑17.

Figure 3‑16: Sending Print Job to Clinical Data Capture Printer

Use to navigate multi-page PDF or TIFF documents

PostScript print converted to PDF

Use to cancel Windows Capture session

Figure 3‑17: View of Document Captured by Clinical Data Capture Printer

Figure 3‑18: Captured/Printed Document with Header

Figure 3‑19: Captured/Printed Document with Footer

The user can submit the captured document using the Submit Document button. Otherwise, to cancel, the user may select the Cancel button or the Note Data or User Settings tabs.

Figure 3‑20: Newly Captured Document

Table 3‑6: Captured Document Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-168	The system shall disable the "Submit" button on the "Windows Application Print Capture" screen until a captured event occurs.	Applicable	Not Applicable	Not Applicable
New DE-169	The system shall dynamically label the "Submit" button on the "Windows Application Print Capture" screen according to selections made in Document Delivery Controls section of the Note Data tab of the Clinical Data Capture panel. Clarification: "Submit" button labels are as follows for both windows application and serial port print jobs: Button label = "Submit Document" if My Inbox = Selected, Auto-Sign = NOT selected, Forward = NOT selected Button label = "Sign & Submit Document" if My Inbox = NOT selected, Auto-Sign = Selected, Forward = NOT selected Button label = "Forward Document" if My Inbox = NOT selected, Auto-Sign = NOT selected, Forward = Selected	Applicable	Not Applicable	Not Applicable
New DE-170	When the Windows Application radio button is selected and Begin Capture button is clicked, the Clinical Data Capture driver shall begin to monitor for any print job coming into the Clinical Data Virtual Printer. Note: The “Submit” button will be disabled until a captured document has been received.	Applicable	Not Applicable	Not Applicable
New DE-171	The system shall display the incoming document/data in the Windows Capture screen of the Clinical Data Capture Module for both windows application and serial port print jobs.	Applicable	Not Applicable	Not Applicable
New DE-171-1	The system shall display document navigation control buttons allowing the user to navigate to the first page, previous page, next page, last page for incoming documents/data in the Virtual Print Capture preview screen on the Clinical Data Capture Module. Clarification: First Page button; Previous Page button; Next Page button; Last Page button.	Applicable	Not Applicable	Not Applicable
New DE-171-2	The system shall display the page number being viewed between the Previous Page and Next Page buttons in the document navigation section in the Virtual Print Capture preview screen on the Clinical Data Capture Module. Clarification: display the label Page followed by a box with the page number followed by of total pages number. (Page 1 of 5)	Applicable	Not Applicable	Not Applicable
New DE-171-3	The system shall display a Scaling box with drop-down scaling options after the Last page button in the document navigation section in the Virtual Print Capture preview screen on the Clinical Data Capture Module. Clarification: Used to set size page within scrollpane's viewport.	Applicable	Not Applicable	Not Applicable
New DE-171-4	The system shall display the following scaling values in Scaling box drop-down in the Virtual Print Capture preview screen on the Clinical Data Capture Module: Fit Width, Fit Height, Fit Page, 25%, 50%, 75%, 100%, 125%, 150%, 200%, 250%, 500%, 750%, 1000%.	Applicable	Not Applicable	Not Applicable
New DE-172	The system shall allow the user to cancel the Windows Capture session by selecting the "Cancel" button at the top of the screen or by selecting the Note Data tab or User Settings tab for both windows application and serial port print jobs.	Applicable	Not Applicable	Not Applicable
New DE-172-1	If the button labeled "Submit” on the Windows Application Printer screen is selected, the system shall display the submitted document as a new entry in the users Documents Inbox Panel.	Applicable	Not Applicable	Not Applicable
New DE-172-2	If the button labeled "Sign & Submit” on the Windows Application Printer screen is selected, the system shall convert document to RTF, along with any embedded images, and send it to the Generic Interface for inclusion into the patient chart as a clinical note.	Applicable	Not Applicable	Not Applicable
New DE-172-3	If the button labeled "Forward” on the Windows Application Printer screen is selected, the system shall store the document in the DE database with document status of Saved.	Applicable	Not Applicable	Not Applicable
New DE-172-4	The system shall display the forwarded document in the Documents Inbox panel of the provider it was forwarded to.	Applicable	Not Applicable	Not Applicable
New DE-180	When "Serial Port Connected Device" is selected and "Begin Capture" is selected the system shall display the Device Print screen and start monitoring for any print job coming into the workstation serial port.	Applicable	Not Applicable	Not Applicable

3.2.3.1.6 Device Capture Operation—Serial Port Connected Device

When the Begin Capture button is activated with the Print Capture option “Serial Port Connected Device” selected, a Device Print screen will display instead of the Windows Print screen, and the Clinical Data Capture driver will begin to monitor the workstation’s serial port for incoming print jobs. The Submit Document button will be disabled until a successful print capture has occurred.

Post-processing of documents captured through Device Capture is the same as for documents captured through Windows Device capture.

Indicator that Clinical Data Capture driver is waiting to receive a print job

Figure 3‑21: Device Capture—Serial Port Connected Device Option

3.2.3.1.7 Document/Data Size Limitation

The CDCM does not impose a fixed document size limitation; AHLTA administrators can configure the limit through business rules. However, due to the 500KB compressed file limit for importing images into the Clinical Notes module, this will be the default size limit for the CDCM.

3.2.3.1.8 User Settings Tab

This tab (see Figure 3‑22) allows the user to configure his/her profile and default settings within the CDCM. The following default metadata can be preconfigured for each user’s profile:

Note Type: The type of document or data. The user can select from a list of note types, configurable by MTF.
Specialty: Definable by MTF based on the available specialties at each site.
Note Title: A short description of the document or data. The drop-down menu displays the last five titles used by the user, which are stored as part of the user preferences cache.
Document Delivery Option: The user can choose My Inbox, Auto-Sign & Submit Document, or Forward Document as the default delivery option for new documents. The Auto-Sign & Submit Document option will be disabled if the user does not have signature authority. When choosing the Forward Document option, the user will be required to use the Provider Search icon to choose a recipient. The system will default to My Inbox unless changed by the user on the User Settings tab.

These settings will be saved to the DE database when the user selects the Save User Default Settings button.

Provider search

Figure 3‑22: CDCM User Settings Tab

Table 3‑7: User Settings Tab Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-146	The system shall allow the user to pre-populate the To field in the Data Delivery Controls section of the Clinical Data Capture panel by setting the To field on the "User Settings" tab of the Clinical Data Capture Panel.	Applicable	Not Applicable	Not Applicable
New DE-184	The system shall allow the user to set a default for the "Note Type" field in the Documentation Information section of the Clinical Data Capture panel by selecting from the drop-down list of Note Types on the "User Settings" tab of the Clinical Data Capture panel. Clarification: The Note Type selected by the user will remain as the user's default until changed by the user and will pre-populate the "Note Type" field each time the user opens the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-185	On the "User Settings" tab of the Clinical Data Capture panel, the system shall allow the user to set a default for the "Specialty" field in the Documentation Information section of the Clinical Data Capture panel by selecting from the drop-down list of Specialties/kinds of care. Clarification: The Specialty selected by the user will remain as the user's default until changed by the user and will pre-populate the "Specialty" field each time the user opens the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-186	On the "User Settings" tab of the Clinical Data Capture panel, the system shall allow the user to set a default "Note Title" for the Note Title field on in the Document Information section of the Clinical Data Capture panel by entering a short description of the document or data. Clarification: The Note Title entered by the user will remain as the user's default until changed by the user and will pre-populate the "Note Title" field each time the user opens the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-186-1	On the "User Settings" tab of the Clinical Data Capture panel, the system shall allow the user to set a default "Note Title" for the Note Title field on in the Document Information section of the Clinical Data Capture panel by selecting a previously used title from the drop-down list in the Note Title field. Clarification: List will display the last 5 titles used by the user	Applicable	Not Applicable	Not Applicable
New DE-188	On the "User Settings" tab of the Clinical Data Capture panel, the system shall allow the user to set a default "Document Delivery Option" for the Data Delivery Control section of the Clinical Data Capture panel by selecting either “My Inbox”, "Auto-Sign & Submit Document" or "Forward Document". Clarification: “Auto-Sign & SubmitDocument” is only available if the provider has signature authority (security object privilege “Current_encounter” = “C” (Can sign)). "Auto-Sign & Submit Document" option will be disabled (grayed out) if the users does not have signature authority. However, the user can still select the "Forward Document" option as their default. If neither option is selected, the system will default to the "My Inbox" option on the "Note Data" tab.	Applicable	Not Applicable	Not Applicable
New DE-189	On the "User Settings" tab of the Clinical Data Capture panel, when the user selects "Forward Document" option, the system shall require the user to select a provider in the “To” field, by using the "Provider Search" icon. . Clarification: “Auto-Sign & Submit Document” is only available if the provider has signature authority (security object privilege “Current_encounter” = “C” (Can sign)). The "Auto-Sign & Select Document" option will be disabled (grayed out) if the user does not have signature authority. However, the user can still select the "Forward Document" option as their default.	Applicable	Not Applicable	Not Applicable
New DE-189-1	The system shall allow the user to access the Provider Search screen, for selecting a provider, from the User Settings tab of the Clinical Date Capture panel.	Applicable	Not Applicable	Not Applicable
New DE-189-2	The system shall allow the user to enter default note text to be defaulted into the Document Content field on the Note Data Tab, from the User Settings tab. Note: This field size is unlimited because it is stored as a CLOB in the Oracle database. CLOBs allow unlimited number of characters.	Applicable	Not Applicable	Not Applicable
New DE-190	When the user has selected the options to be set and selects "Save User Default Settings" the system shall save the selected settings for this user to the Document Engine database. Clarification: To cancel without saving user settings, select Note Data tab.	Applicable	Not Applicable	Not Applicable

3.2.4 DIM

The DIM is the user’s primary tool for viewing, editing, delegating, and signing documents. The user context is the only context this module requires from the AHLTA client.

The DIM will be accessed from the Desktop node of the user Folder List pane. When activated, the DIM will be rendered in a web container.

Although AHLTA currently only supports outpatient documentation, the DIM supports the receipt of both inpatient and outpatient documents from external vendors. Incoming inpatient documents will have Inpatient status while outpatient documents will have Outpatient status.

In addition to providing access to outpatient documents, the DIM will provide access to inpatient documents, but only for the MTF’s Patient Administration/Inpatient Records group and its satellite offices. This is so that the inpatient documents can be printed and included in the patient’s chart. The functionality for the inpatient records versus the outpatient records within the DIM is slightly different and will be further explained in subsequent sections. Only users who have been given the new security key “DOCUMENT_INBOX_INPATIENT” will see the inpatient documents in the DIM.

3.2.4.1 Documents Inbox Panel

Upon accessing the DIM, the system will display the Documents Inbox panel as its default view. The DE will check the AHLTA user context, and, based on the user’s privileges, will display either the Documents Inbox view or the Inpatient Documents Inbox view.

3.2.4.1.1 Documents Inbox View

The Documents Inbox view as shown in Figure 3‑23 and Figure 3‑24 (enlarged view) is the default view for users who do not belong to the Patient Administration/Inpatient Records group. This panel consists of a table listing all unsigned documents associated with the current user that have been received either as a dictation or through the CDCM. Note that the Documents Inbox can contain both outpatient and inpatient documents. Upon users signing, forwarding, or reassigning a document from this inbox, the document will be removed from their Inbox panel.

Use to load Document Engine Module

Figure 3‑23: Documents Inbox Panel for User with Inpatient Records Privilege

Use to activate filtering operation

Original Date of Document

Sorting controls

Filter options

Figure 3‑24: Enlarged View of Documents Inbox Panel for User with Inpatient Records Privilege

Figure 3‑25: Documents Inbox Panel for Users without Inpatient Records Privilege

Sorting controls

Use to activate filtering operation

Filter options

Original Date of Document

Figure 3‑26: Enlarged View of Documents Inbox Panel for Users without Inpatient Records Privilege

A number of controls are available on this Documents Inbox panel. They are as follows:

Inbox Filters: This drop-down menu enables users to apply the following filter criteria to the documents listed in this Documents Inbox:
- All: displays all of the documents currently assigned to the user. This will be the default filter set upon the user accessing the inbox each session.
- Outpatient Only: filters any documents where the patient status is not Outpatient.
- Inpatient Only: filters any documents where the patient status is not Inpatient.
- Today Only: filters any documents that do not have the current date associated with them.
- Last 5 Days: filters based on the original date of the document. Any documents that are more than five days old are not displayed.
- Last 10 Days: filters based on the original date of the document. Any documents that are more than 10 days old are not displayed.
- Last 20 Days: filters based on the original date of the document. Any documents that are more than 20 days old are not displayed.
- Apply Filter: applies the selected filter to Documents Inbox.
- Documents Inbox Sort Controls: users can sort columns in the Documents Inbox by selecting the up/down arrows icons located in the column headers. By selecting the icon, the list is sorted in either ascending or descending order.

3.2.4.1.2 Inpatient Documents Inbox

The Inpatient Documents Inbox is available only to users who belong to the Patient Administration/Inpatient Records group (users with the DOCUMENT_INBOX_INPATIENT security object/key). The Inpatient Documents Inbox consists of a table listing all inpatient documents, which have been signed and submitted by the provider, for the facility that the user is logged into. The user group with access to this inbox will be allowed to print, forward, or delete the inpatient documents. Figure 3‑27 displays the Inpatient Documents Inbox. This panel consists of an inpatient Location drop-down menu and a table listing all signed documents associated with the location listed in the drop-down menu. These signed documents can have a status of either SIGNED or PRINTED.

NOTE: Users with access to the Inpatient Documents Inbox are not expected to capture or dictate any documents.

Use to forward selected document

Use to delete selected document

Use to print selected document

Use to activate filtering operation

Filter options

Figure 3‑27: Enlarged View of Inpatient Documents Inbox Panel

A number of controls are available on this Inpatient Documents Inbox panel. They are as follows:

Record Room: This drop-down menu allows the user to filter the view of documents based on inpatient record locations (e.g., Main Records, Neonatal Intensive Care Unit [ICU], 1NORTH).

NOTE: These inpatient locations are configurable by each MTF. For each inpatient location, a printer must also be designated and configured for printing by the DES in order to affect the Print operation. All information regarding inpatient locations and printer will be persisted in the DE database. Furthermore, one location will be designated as the default location to which all signed inpatient documents will be sent initially. This location will be the default display when the Inpatient Documents Inbox is displayed.

Change Record Room: When this button is selected, the system will display all inpatient documents associated with the record room displayed in the Record Room field.
Inbox Filters: This drop-down menu enables the user to apply the following filter criteria to the documents listed in the panel:
- All: displays all of the documents assigned to the inpatient location displayed in the Location field.
- Today Only: filters any documents that do not have the current date associated with them.
- Last 5 Days: filters based on the original date of the document. Any documents that are more than five days old will not be displayed.
- Last 10 Days: filters based on the original date of the document. Any documents that are more than 10 days old will not be displayed.
- Last 20 Days: filters based on the original date of the document. Any documents that are more than 20 days old will not be displayed.
- Apply Filter: When this button is selected, the system will perform the filtering based on the selection in the Inbox Filter control.
- Print: When this button is selected, the system will locate the printer associated with the inpatient location designated on the Location drop-down menu and will issue a print job to that printer for each of the documents selected. All print jobs will be performed as background processes. Upon selecting the Print action, all selected documents will have their status change to PRINTED (i.e., document with preprinted status of SIGNED will become PRINTED, documents with preprinted status of PRINTED will remain PRINTED).

Any document can be selected for printing regardless of its status. A user can select multiple documents for printing.

Delete: When this button is selected, the system will delete all references to the selected documents from the DE database, except for its auditing information. The user will no longer see the documents in the Documents Inbox. The user can select multiple documents for deletion.

Only documents with PRINTED status shall be deleted by the system. If the user inadvertently selects documents with SIGNED status, the system will display a warning message (Figure 3-28).

Figure 3‑28: Warning Message for Delete

Forward: When this button is selected, the user will be prompted to select from a list of preconfigured inpatient locations to which to forward the document(s). Once forwarded, these documents will no longer be visible to the inpatient location from which the document was forwarded. The document will be visible when the user changes the Location drop-down menu to the new forwarded inpatient location.

Any document can be selected for forwarding regardless of its status. The user can select multiple documents for this operation.

Table 3‑8: Documents Inbox Panel Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-191-1	Upon selecting a document in the Documents Inbox panel while in the Clinical Data Capture module, the system shall navigate the user to the Documents Inbox module and display the Document Editor panel with the selected document open for editing. Business Rule: This requires Read, Write access to the DOCUMENT_INBOX security object in the Security Matrix. Clarification: The manner in which a document is selected is dependent upon the users Inbox privilege. If a user has Inpatient Records privilege then selection is made by checking a box in the Select column. If a user does not have Inpatient Record privilege then selection is made by clicking on an ID link.	Applicable	Not Applicable	Not Applicable
New DE-191	When a user selects "Documents Inbox" from the "Tools Folder" in the Folder List or from the Go Menu or the Toolbar, the system shall display the Provider Documents Inbox panel. Business Rule: This requires Read, Write access to the DOCUMENT_INBOX security object in the Security Matrix. Clarification: This panel consists of a table listing (as links) all un-signed documents (inpatient and outpatient) associated with the logged-in user that have been received either as a dictation or through the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-191-2	When a user with the DOCUMENT_INBOX_INPATIENT security key selects "Documents Inbox" from the "Tools Folder" in the Folder List, or from the Go Menu or the Toolbar, the system shall display the Inpatient Documents Inbox panel. Clarification: This panel consists of a table listing (as links) of all signed inpatient documents for that MTF.	Applicable	Not Applicable	Not Applicable
New DE-305	The system shall not refresh the patient ID bar when the user first enters the Documents Inbox module. Clarification: The patient ID bar will only be refreshed when the user selects a row in the Documents Inbox display that has an associated patient different from the patient displayed in the Patient ID bar.	Applicable	Not Applicable	Not Applicable
New DE-306	The system shall refresh the patient ID bar with the patient that is associated with the document the user has currently selected from the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-204	The system shall display the following options for Documents Inbox panel: Documents Inbox Sort Controls, Inbox Filters selection, Apply Filter button, Print, Delete, and Forward.	Applicable	Not Applicable	Not Applicable
New DE-205	The system shall display Sorting Controls (up and down arrow) in each of the column headers of the Documents Inbox, to allow the user to sort the list of documents in either ascending or descending order based on the column sort control selected.	Applicable	Not Applicable	Not Applicable
New DE-206	The system shall allow the user to select an Inbox Filter from a drop-down list at the bottom of the Documents Inbox view.	Applicable	Not Applicable	Not Applicable
New DE-206-1	Upon selecting the drop-down arrow in the Inbox Filters field on the Documents Inbox, the system shall display the following filters: All, Outpatient Only, Inpatient Only, Today Only, Last 5 Days, Last 10 Days, and Last 20 Days.	Applicable	Not Applicable	Not Applicable
New DE-206-1.1	Upon selecting “All” option in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall display all the documents in the provider’s inbox.	Applicable	Not Applicable	Not Applicable
New DE-206-2	Upon selecting “Outpatient Only” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a Patient Status of Outpatient.	Applicable	Not Applicable	Not Applicable
New DE-206-3	Upon selecting “Inpatient Only” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a Patient Status of Inpatient.	Applicable	Not Applicable	Not Applicable
New DE-206-4	Upon selecting “Today Only” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have the current system date in the Date column.	Applicable	Not Applicable	Not Applicable
New DE-206-5	Upon selecting “Last 5 Days” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 5 days from the current date.	Applicable	Not Applicable	Not Applicable
New DE-206-6	Upon selecting “Last 10 Days” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 10 days from the current date.	Applicable	Not Applicable	Not Applicable
New DE-206-7	Upon selecting “Last 20 Days” in the Inbox Filters control on the Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 20 days from the current date.	Applicable	Not Applicable	Not Applicable
New DE-207	Upon selecting the "Apply Filter" button on the bottom of the Provider Documents Inbox the system shall filter the Provider Documents Inbox according to the selection in the Inbox Filter field.	Applicable	Not Applicable	Not Applicable
New DE-400	The system shall display the following options for Inpatient Documents Inbox panel: Record Room Filter Selection, Documents Inbox Sort Controls, Inbox Filters selection, and Apply Filter, Print, Delete, and Forward buttons.	Applicable	Not Applicable	Not Applicable
New DE-401	The system shall allow the user to filter the Inpatient Documents Inbox panel by selecting an inpatient record room location from the Record Room field drop-down list. Clarification: This list is configured by the MTF.	Applicable	Not Applicable	Not Applicable
New DE-402	Upon selecting the Change Record Room button on the Inpatient Documents Inbox panel, the system shall filter the document list by the inpatient record room location displayed in the Record Room field.	Applicable	Not Applicable	Not Applicable
New DE-403	The system shall display Sorting Controls (up and down arrow), in each of the column headers of the Inpatient Documents Inbox, to allow the user to sort the list of documents in either ascending or descending order based on the column sort control selected.	Applicable	Not Applicable	Not Applicable
New DE-404	The system shall allow the user to select an Inbox Filter from a drop-down list at the bottom of the Inpatient Documents Inbox view.	Applicable	Not Applicable	Not Applicable
New DE-405	Upon selecting the drop-down arrow in the Inbox Filters control on the Inpatient Documents Inbox, the system shall display the following filters: All, Today Only, Last 5 Days, Last 10 Days, and Last 20 Days.	Applicable	Not Applicable	Not Applicable
New DE-405-1	Upon selecting “All” option in the Inbox Filters control on the Inpatient Documents Inbox view, the system shall display all the documents in the document inbox for that inpatient Record Room location.	Applicable	Not Applicable	Not Applicable
New DE-406	Upon selecting “Today Only” in the Inbox Filters control on the Inpatient Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have the current system date in the Date column.	Applicable	Not Applicable	Not Applicable
New DE-407	Upon selecting “Last 5 Days” in the Inbox Filters control on the Inpatient Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 5 days from the current system date.	Applicable	Not Applicable	Not Applicable
New DE-408	Upon selecting “Last 10 Days” in the Inbox Filters control on the Inpatient Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 10 days from the current system date.	Applicable	Not Applicable	Not Applicable
New DE-409	Upon selecting “Last 20 Days” in the Inbox Filters control on the Inpatient Documents Inbox view and clicking the Apply Filter button, the system shall filter the document panel to display only documents that have a date within the last 20 days from the current system date.	Applicable	Not Applicable	Not Applicable
New DE-410	Upon selecting the "Apply Filter" button on the bottom of the Inpatient Documents Inbox the system shall filter the Inpatient Documents Inbox according to the selection in the Inbox Filter field.	Applicable	Not Applicable	Not Applicable
New DE-411	The system shall allow the user to select a document in the Inpatient Document panel by selecting the checkbox in the Select column	Applicable	Not Applicable	Not Applicable
New DE-412	The system shall allow the user to select multiple documents in the Inpatient Document panel by selecting the checkboxes in the Select column	Applicable	Not Applicable	Not Applicable
New DE-413	The system shall allow the user to print inpatient documents from the Inpatient Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-414	When the Print button is selected on the Inpatient Documents Inbox panel, the system shall print the selected documents to a pre-configured printer associated to the location set in the Location field.	Applicable	Not Applicable	Not Applicable
New DE-415	Upon selecting the Print button from the Inpatient Document Inbox, the system shall change the document status from Signed to Printed. Clarification: If the document status is already Printed when the print action is taken, the status shall remain the same.	Applicable	Not Applicable	Not Applicable
New DE-416	When the Delete button is selected on the Inpatient Documents Inbox panel, the system shall remove the selected documents from the Inpatient Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-417	The system shall only allow the user to delete documents from the Inpatient Documents Inbox that are in a Printed document status.	Applicable	Not Applicable	Not Applicable
New DE-418	The system shall display a warning message if the user selects the Delete button and a document in “Signed” status is selected. Clarification: Standard Windows Error Message box will state “The following Notes cannot be deleted because status is not PRINTED: Notes XXXXX, XXXXX (XXXXX = note numbers).”	Applicable	Not Applicable	Not Applicable
New DE-419	The system shall allow the user to forward a selected document(s) to another inpatient Record Room from the Inpatient Documents Inbox. Clarification: for documents in both the Signed and Printed status.	Applicable	Not Applicable	Not Applicable
New DE-420	When the Forward button is selected on the Inpatient Documents Inbox panel, the system shall prompt the user to select from a pre-defined set of inpatient locations to select where to forward the document to.	Applicable	Not Applicable	Not Applicable
New DE-421	Upon selecting the inpatient Record Room location to forward to, the system shall remove the selected documents from the forwarding inpatient Record Room location view.	Applicable	Not Applicable	Not Applicable
New DE-422	Upon the user forwarding a document to another inpatient Record Room location, the system shall display the forwarded documents in the Inpatient Documents Inbox for the inpatient Record Room location the documents were forwarded to.	Applicable	Not Applicable	Not Applicable
New DE-423	Upon forwarding a document from the Inpatient Documents Inbox, the system shall not change the Status of the document.	Applicable	Not Applicable	Not Applicable

3.2.4.1.3 Documents Inbox Metadata

Each document, in both the Documents Inbox and the Inpatient Documents Inbox, is displayed with the following metadata:

ID: Specific document ID in the DE database. A link is associated with each ID, enabling the user to navigate to the Document Editor panel.
Date: Date the document was dictated or captured. For captured documents, the date is the Original Date of Document listed on the Note Data tab of the CDCM.
Patient: Name of the patient with whom the document is associated.
Patient Status: Inpatient/outpatient status of the patient at the time the document was received or captured.

NOTE: This data is for the Documents Inbox only.

Provider: The original owner of the document.
Source/Note Type: How the document was generated and the type of dictation or captured document. The Captured label will be used to denote any documents obtained using the CDCM. The Transcribed label will be used to denote any documents received from external systems.
Specialty: Clinical service/specialty of the user who dictated or captured the document.
Status: The current state of the document. The following are the primary states that will be implemented:
- TRANSCRIBED: Transcribed is the initial state of all documents received from external systems via HL7 interfaces. This status is not available for the Inpatient Documents Inbox.
- SAVED: This is the initial state of all documents captured via the CDCM. A document can also enter this state if the user makes changes to the document but is not ready to sign off. This status is not available for the Inpatient Documents Inbox.
- STAFF SIG REQUESTED: A document enters this state if it is forwarded for signature by a provider with no signature authority. This status is not available for the Inpatient Documents Inbox.
- REASSIGNED: A document enters this state if it is reassigned for signature or for counter-signature by a provider with signature authority. This status is not available for the Inpatient Documents Inbox.
- REVISIONS REQUESTED: A document enters this state when the user chooses the Return for Revisions action. This status is not available for the Inpatient Documents Inbox.
- SIGNED: A document enters this state when a user signs off on a document. This status is only available for the Inpatient Documents Inbox.
- PRINTED: A document enters this state when it has been printed from the Inpatient Documents Inbox. This status is only available for the Inpatient Documents Inbox.
- PENDING TRANSMISSION: Only signed documents can enter this state. While these documents are being transmitted to the CDR, the DE will mark these documents with this status until successful transmission has been achieved. This status is not available for the Inpatient Documents Inbox.

Table 3‑9: Documents Inbox Metadata Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-192	The system shall display the following metadata for each document in the “Documents Inbox” view: ID, Date, Patient, Patient Status, Provider, Source/Note Type, Specialty, and Status	Applicable	Not Applicable	Not Applicable
New DE-193	In the "Documents Inbox" view, the system shall display the ID number which represents a specific document in the Document Engine database along with a link associated with the ID.	Applicable	Not Applicable	Not Applicable
New DE-193-1	Upon the user selecting a document by clicking on the ID link the system shall display the selected document in the Editor Panel of the Documents Inbox Module.	Applicable	Not Applicable	Not Applicable
New DE-194	In the "Documents Inbox" view, the system shall display the Date the document was dictated or captured.	Applicable	Not Applicable	Not Applicable
New DE-195	In the "Documents Inbox” view, the system shall display the name of the Patient that the document is associated with.	Applicable	Not Applicable	Not Applicable
New DE-196	In the "Documents Inbox" view, the system shall display the Patient Status as Inpatient or Outpatient at the time the document was received or captured.	Applicable	Not Applicable	Not Applicable
New DE-196-1	The system shall default all documents captured through the Clinical Data Capture module to a Patient Status of “Outpatient”.	Applicable	Not Applicable	Not Applicable
New DE-196-2	In the Documents Inbox view, the system shall display the document Source/Note Type of “Captured for documents obtained from the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-196-3	In the Documents Inbox view, the system shall display the document Source/Note Type of “Transcribed” for documents obtained from external systems.	Applicable	Not Applicable	Not Applicable
New DE-197	In the “Documents Inbox" view, the system shall display the Specialty (or Clinical Service) of the user who dictated or captured the document.	Applicable	Not Applicable	Not Applicable
New DE-198	In the “Documents Inbox" view, the system shall display the Status (Current State) of the document as one of the following: Transcribed, Saved, Staff Sig Requested, Revision Requested, Reassigned, and Pending Transmission.	Applicable	Not Applicable	Not Applicable
New DE-199	In the “Documents Inbox" view, the system shall display the Status of the document as "Transcribed" as the initial state of all documents received from a transcription service.	Applicable	Not Applicable	Not Applicable
New DE-200	In the “Documents Inbox" view, the system shall display the Status of the document as “Saved" as the state of all documents captured via the Clinical Data Capture module. NOTE: Document can also enter this state if the user makes changes to the document but is not ready to sign off.	Applicable	Not Applicable	Not Applicable
New DE-201	In the “Documents Inbox" view, the system shall display the Status of the document as “Staff Sig Requested" as the state of documents that have been forwarded for signature by a user without signature authority.	Applicable	Not Applicable	Not Applicable
New DE-201-1	In the “Documents Inbox” view, the system shall display the Status of the document as “Reassigned" as the state of documents that have been reassigned to another user by a provider with signature authority.	Applicable	Not Applicable	Not Applicable
New DE-201-2	In the “Documents Inbox” view, the system shall display the Status of the document as “Revision Requested" as the state of documents that have been returned to the forwarding user for clarification/revision.	Applicable	Not Applicable	Not Applicable
New DE-201-3	In the “Documents Inbox" view; the system shall display the Status of the document as” Pending Transmission" as the state of the document that have been signed but are pending transmission.	Applicable	Not Applicable	Not Applicable
New DE-201-4	The system shall display the following columns in the Inpatient Documents Inbox view: Select, ID, Date, Patient, Provider, Source/Note Type, Specialty, and Status.	Applicable	Not Applicable	Not Applicable
New DE-201-5	In the "Inpatient Documents Inbox" view, the system shall display the ID number which represents a specific document in the Document Engine database along with a link associated with the.ID.	Applicable	Not Applicable	Not Applicable
New DE-201-5.1	Upon the user selecting ID by checking the box in the Select column, the system shall display the selected document in the Document Editor Panel of the Documents Inbox Module.	Applicable	Not Applicable	Not Applicable
New DE-201-6	In the "Inpatient Documents Inbox" view, the system shall display the Date the document was dictated or captured.	Applicable	Not Applicable	Not Applicable
New DE-201-7	In the "Inpatient Documents Inbox” view, the system shall display the name of the Patient that the document is associated with.	Applicable	Not Applicable	Not Applicable
New DE-201-8	In the Inpatient Documents Inbox view, the system shall display the document Source/Note Type. Clarification: “Captured” shall display for documents obtained from the Clinical Data Capture module and “Transcribed” shall display for documents obtained from external systems.	Applicable	Not Applicable	Not Applicable
New DE-201-9	In the "Inpatient Provider Documents Inbox", the system shall display the Specialty (or Clinical Service) of the user who dictated or captured the document.	Applicable	Not Applicable	Not Applicable
New DE-201-10	In the "Inpatient Provider Documents Inbox", the system shall display the Status (Current State) of the document as one of the following: Signed or Printed.	Applicable	Not Applicable	Not Applicable

3.2.4.1.4 Document Editor Panel

After a document is selected from the Documents Inbox, the DIM will display a Document Editor panel (see Figure 3‑29) to the right of the Documents Inbox panel. The Documents Inbox panel can be toggled in and out of view using the Editor Only View button available on the Document Editor panel. The label of this button changes to Inbox/Editor View when hiding the Documents Inbox panel. Selecting this button will bring the Documents Inbox panel back into view.

The following additional action is available on the Documents Inbox panel after a document is selected:

Return To Document Capture Button: This button returns the user to the CDCM if the user navigated to the current location via the Documents Inbox panel shortcut in this module. This button is not available for users who accessed the Documents Inbox via the folder menu tree.

Return user to the CDCM

Use to activate the filtering operation

Filter options

Figure 3‑29: DIM Showing Selected Document

3.2.4.2 Document Editor Panel

The Document Editor panel has the following three tabs: Editor, Revisions, and Attachments. The Editor tab is the default view. Each tab allows the user to perform a number of functions as described in the following sections.

Table 3‑10: Document Editor Panel Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-203	When the user selects a document ID from the Documents Inbox view, the system shall display the Document Editor panel to the right of the Documents Inbox panel.	Applicable	Not Applicable	Not Applicable
New DE-203-1	The system shall allow the user to hide the Documents Inbox, when the Document Editor panel is displayed. Clarification: via the Editor Only View button on the Document Editor panel.	Applicable	Not Applicable	Not Applicable
New DE-203-2	The system shall allow the user to display the Documents Inbox, when the Document Editor panel is displayed. Clarification: via the Inbox/Editor View button on the Document Editor panel.	Applicable	Not Applicable	Not Applicable
New DE-208	The system shall allow the user to navigate back to the Clinical Data Capture module by selecting the "Return to Document Capture" button at the bottom right side of the Documents Inbox panel. Clarification: button only displays if the user navigated to the Documents Inbox module via the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-209	The Document Editor panel shall consist of three tabs labeled "Editor", "Revisions", and "Attachments".	Applicable	Not Applicable	Not Applicable
New DE-209-1	The “Editor” tab shall be displayed as the default tab on the Document Editor panel.	Applicable	Not Applicable	Not Applicable
New DE-210	The "Editor" tab shall consist of three sections: the "Document Metadata Section" on the top half of the panel; the "Document Content Section" on the bottom half of the panel; and the "Document Action Controls Section" at the bottom of the screen.	Applicable	Not Applicable	Not Applicable
New DE-211	The system shall display in the Document Metadata section the metadata collected when the document was dictated or captured including: Original Date of Document; Patient; Patient Status; Note Type; Document Status; Specialty; Note Title; Associated Encounter; and Associated Clinic.	Applicable	Not Applicable	Not Applicable
New DE-211-1	The system shall allow the user to edit the Patient Status field from the Document Editor panel. Clarification: options are Inpatient and Outpatient.	Applicable	Not Applicable	Not Applicable
New DE-211-2	The system shall allow the user to edit the Specialty field from the Document Editor panel.	Applicable	Not Applicable	Not Applicable
New DE-211-3	The system shall allow the user to edit the Associated Clinic field from the Document Editor panel.	Applicable	Not Applicable	Not Applicable
New DE-260	The system shall allow the user the ability to change the associated encounter from the Document Editor tab. Clarification: via the encounter search icon located to the right of the Associated Encounter field	Applicable	Not Applicable	Not Applicable
New DE-260-1	Upon selecting the Encounter Search icon on the Document Editor tab, the system shall display a list of open and closed encounters for the patient associated to the document. Clarification: list includes open and closed encounters from within the past 2 months from the system date. Only available for transcribed documents.	Applicable	Not Applicable	Not Applicable
New DE-260-8	The system shall display the following metadata for each encounter displayed in the list of available open and closed encounters: Date, Clinic, Provider, and Status.	Applicable	Not Applicable	Not Applicable
New DE-260-9	The system shall allow the user the ability to select an encounter from the list of encounters displayed to the user when the Encounter Search screen is selected. Clarification: By selecting the checkbox in the Select column for the encounter.	Applicable	Not Applicable	Not Applicable
New DE-260-2	Upon selecting an encounter from the list displayed from selecting the encounter search icon, the system shall return the user to the Document Editor screen and populate the Associated Encounter field with the selected encounter date and time displayed in the Associated Encounter field.	Applicable	Not Applicable	Not Applicable
New DE-260-10	The system shall allow the user the ability to return to the Document Editor tab without selecting an encounter. Clarification: via the Cancel button.	Applicable	Not Applicable	Not Applicable
New DE-260-3	If upon displaying the Document Editor tab, there is no encounter associated to the document, the system shall display the Associated Encounter field blank.	Applicable	Not Applicable	Not Applicable
New DE-260-3.1	If the user changes the Associated Encounter field on the Document Editor screen, the system shall update the Associated Clinic field with the clinic associated to the newly selected encounter. Clarification: If the newly selected encounter does not have an associated clinic, the Associated Clinic field will display blank.
New DE-260-4	When a document is selected from the Documents Inbox whose origin was the Clinical Data Capture module (non- transcribed), the system shall disable the Associated Encounter field and display the field blank.	Applicable	Not Applicable	Not Applicable
New DE-260-5	The system shall allow the user to change the Associated Clinic field from the Document Editor screen. Clarification: via the Clinic Search icon located to the right of the Associated Clinic field.	Applicable	Not Applicable	Not Applicable
New DE-260-6	Upon selecting the Clinic Search icon from the Document Editor screen, the system shall display the Clinic Search screen.	Applicable	Not Applicable	Not Applicable
New DE-260-7	Upon selecting a clinic from the Clinic Search screen accessed from the Document Editor, the system shall return the user to the Document Editor screen with the selected clinic displayed in the Associated Clinic field.	Applicable	Not Applicable	Not Applicable

3.2.4.2.1 Editor Tab

In addition to displaying the content of the selected document on the Editor tab (see Figure 3‑30), the various metadata collected and associated with this document are also shown. The three distinct sections that make up this tab (Document Metadata section, Document Content section, and Document Action Controls section) are described in the following sections.

Use to trigger a print operation.

“Clinic Search” icon

“Encounter Search” icon

Figure 3‑30: Editor Tab of the Document Editor Panel

Document Metadata Section

This section displays metadata collected when the document was captured. A user can supply additional metadata or change the existing editable values.

Original Date of Document (required/noneditable): Date the document was captured or dictated.
Patient (required/noneditable): Patient with whom this document is associated.
Patient Status (required/editable): Inpatient/outpatient status of the patient when the document was captured or dictated. Documents captured via the CDCM will default to Outpatient.
Note Type (required/editable): The type of dictation or captured document.
Document Status (required/noneditable): The current state of the document.
Specialty (required/editable): The specialty of the user who captured or dictated the document.
Note Title (optional/editable): Short description of the document or data.
Associated Encounter (optional/editable): The encounter associated with the document. A user can use the Encounter Search icon to locate available encounters. When a search is initiated, the user will be shown a list of open and closed encounters within the last two months for the selected patient. When an encounter is selected, the Attachments tab will be disabled.

NOTE: This option is only available for transcribed documents. This field will be disabled if the selected document was captured using the CDCM.

Associated Clinic (optional/editable): By default, this field will display the clinic referenced by the selected encounter. The user has the option to search for a different clinic by using the Clinic Search icon. Selecting this icon will prompt the system to render a Clinic Search screen where the user will be able to select an appropriate clinic.

Document Content Section

This section displays the content of the document and allows the user to make further content changes. Note that binary documents (e.g., most images) are not editable.

Note Text Area: This area is completely editable.
Formatting: A number of formatting functions are provided for the user, such as Font, Font Size, Bold, Italic, Underline, Align Left, Align Right, and Align Center, in order to format the content of the Note Text area.
Print Capability: This prints the document.

Document Action Controls Section

This section describes a number of actions the user can perform on the document. They are as follows:

Sign and Submit: This action is only available to users who have signature authority. When the user signs off on an outpatient-related document, the DE submits the final version to AHLTA. If the document is not associated with an encounter, it will be submitted to AHLTA through the Generic Interface. If the document is associated with an encounter, it will be submitted to the encounter as an AddNote through the JavaScript API to be developed in support of the DE Integration project. If the document is inpatient-related and the user signs off on the document, the system will check the Note Type to determine where the document is sent. If the Note Type is determined to be Consult, Narrative Summary, Operative Report, or Procedure Report, the system shall send the signed document to the CDR for inclusion into the Clinical Note module for the patient as well as assign it to the Inpatient Documents Inbox to be printed and inserted into the patient’s paper chart. If the Note Type is determined to be something other than the four listed above, the system will assign it to the Inpatient Documents Inbox only with a status of Signed. The table below describes the different actions to be performed by the system for each document based on its Patient Status and Encounter metadata.

Table 3‑11: Sign and Submit Button Actions

Patient Status	Encounter	Action
Outpatient	Yes	System will convert document to rich text format (RTF) with no embedded images. System will send document to CDR for inclusion into the selected Encounter Note via the Add Note Interface.
Outpatient	No	System will convert document to RTF format with embedded images (if any). System will send the document to CDR via the Generic Interface for inclusion into patient chart as a Clinical Note. System will direct user to Documents Inbox with document’s status changed to PENDING TRANSMISSION. Upon a successful confirmation from CDR, system will purge document from database including its metadata and versions with the exception of audit information. When Documents Inbox is refreshed, document will no longer be listed.
Inpatient	Yes	System will convert document to RTF format with no embedded images. System will send document to CDR for inclusion into the selected Encounter Note via the Add Note Interface. System will send document to Inpatient Documents Inbox with its status changed to SIGNED and assigned to a default location. The signed document will display as a new entry in the Inpatient Documents Inbox Panel for any users with “IRG” privilege to access.
Inpatient	No	System will send document to Inpatient Documents Inbox with its status changed to SIGNED and assigned to a default location. The signed document will display as a new entry in the Inpatient Documents Inbox Panel for any users with “IRG” privilege to access. If the document’s note type is of category Consultation, Operative Report, Procedure Report, or Narrative Summary Report, the system will also convert document to RTF format with no embedded images and send it to CDR for inclusion into the selected Encounter Note via the Add Note Interface. System will direct user to Documents Inbox with document no longer listed.

Save Draft: Saves changes to the current document. Places the document in a Saved status.
Delete: Removes current document from DE database.
Forward: Forwards the document to another user who has signature authority. When this button is pressed, the user will be directed to a Provider Search screen where he/she can locate an appropriate provider.

NOTE: This action is only available to users who do not have signature authority (e.g., residents, interns).

When this operation is completed, the user will return to the Documents Inbox screen where this document will no longer be visible for access by this user. This document will be visible on the Documents Inbox of the provider who was selected from the Provider Search screen in Staff Sig Requested status.

Reassign: Forwards the document to another signature-authorized user for review and signature.

NOTE: This action is only available to users who have signature authority.

When this operation is completed, the user will return to the Documents Inbox screen where this document will no longer be visible for access by this user. This document will be visible on the Documents Inbox of the provider who was selected from the Provider Search screen in Reassigned status.

Return for Revision: Returns forwarded documents to the original sender for clarifications/revisions. When this operation is completed, the user will return to the Documents Inbox screen where this document will no longer be visible for access by this user. This document will be visible on the Documents Inbox of the user who originally forwarded the document in a Revision Requested status.

Table 3‑12: Editor Tab Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-300	Upon the user selecting the "Sign & Submit Document" button within the Print Capture display in the Note Data tab of the Clinical Data Capture module, the system shall store the document in the Clinical Notes module.	Applicable	Not Applicable	Not Applicable
New DE-301	Upon submitting a document as a Clinical Note for the selected patient from the Print Capture display of the Clinical Data Capture module, the application shall set the Note Type field in the Clinical Notes module to the Note Type field in the Note Data tab of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-302	Upon submitting a document as a Clinical Note for the selected patient from the Print Capture display of the Clinical Data Capture module, the application shall set the date field in the Clinical Notes module to the "Original Date of Document" field from the Note Data tab of the Clinical Data Capture module.	Applicable	Not Applicable	Not Applicable
New DE-303	Upon submitting a document as a Clinical Note for the selected patient from the Print Capture display of the Clinical Data Capture module, the application shall set the clinician field in the Clinical Notes module to the current logged in user.	Applicable	Not Applicable	Not Applicable
New DE-304	Upon submitting a document as a Clinical Note for the selected patient from the Print Capture display of the Clinical Data Capture module, the application shall default the POC field in the Clinical Notes module to the MTF where the user is currently logged in.	Applicable	Not Applicable	Not Applicable
New DE-212	In the "Document Content Section" of the Document Editor tab the system shall display the content of the dictated or captured document.	Applicable	Not Applicable	Not Applicable
New DE-213	In the "Document Content Section" of the Document Editor tab the system shall allow the user to make changes to the document. Clarification: The Note text area is completely editable. The format area provides the user with the following formatting functions: Font, Font Size, Bold, Italic, Underline, Align Left, Align Right, and Center.	Applicable	Not Applicable	Not Applicable
New DE-213-1	The system shall allow the user to select the font type by selecting from the drop down list of fonts available in the formatting tool area of the "Document Content" section of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-2	The system shall allow the user to select the font size by selecting from the drop down list of font sizes available in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-3	The system shall allow the user to select the bold font attribute by selecting the “bold” icon in the formatting tool area of the "Document Content" section of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-4	The system shall allow the user to select the italic font attribute by selecting the “italic” icon in the formatting tool area of the "Document Content" section of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-5	The system shall allow the user to select the underline font attribute by selecting the “underline” icon in the formatting tool area of the "Document Content" section of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-6	The system shall allow the user to left-justify the document by selecting the “left-justify” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the Document Editor tab of the Documents Inbox..	Applicable	Not Applicable	Not Applicable
New DE-213-7	The system shall allow the user to right-justify the document by selecting the “right-justify” icon in the formatting tool area of the "Document Content" of the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-8	The system shall allow the user to center the document by selecting the “center” icon in the formatting tool area of the "Document Content" section, for the note explanation in the "Document Content" section of the Document Editor tab.	Applicable	Not Applicable	Not Applicable
New DE-213-9	The system shall allow the user to print the document from the Document Editor tab of the Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-213-10	The system shall mark printed unsigned documents printed from the Document Editor tab of the Documents Inbox with a “Draft” watermark.	Applicable	Not Applicable	Not Applicable
CFR18358-1	The system shall include a footer on all pages of a printed document that contains the name of the user who printed out the document. Clarification: For all document types (transcribed and captured). The footer will also print on all pages when a transcribed document is printed.	Applicable	Not Applicable	Not Applicable
CFR18358-2	The system shall include in the footer on all pages of a printed document the workstation date and time that a document was printed. Clarification: For all document types (transcribed and captured).	Applicable	Not Applicable	Not Applicable
CFR18359-1	The system shall include a header on all pages of the printed “transcribed” document to display: the Dictating Provider, Dictation Date, MTF, and Note Type. Clarification: For transcribed documents only.	Applicable	Not Applicable	Not Applicable
CFR18359-2	The system shall include a header on all pages of the printed “captured” document to display: Captured By, Captured Date, MTF, and the Note Type.	Applicable	Not Applicable	Not Applicable
CFR18361-1	The system shall include the name of the signing provider on the printed transcribed document.	Applicable	Not Applicable	Not Applicable
New DE-214	In the "Document Action Controls Section" at the bottom of the Editor tab the system shall display six buttons: "Sign and Submit", "Save Draft", "Delete", "Forward", "Reassign", and "Return for Revisions".	Applicable	Not Applicable	Not Applicable
New DE-214-1	Upon submitting a document as an Add Note to the selected encounter, the system shall default the Note Type field in the Encounter Note dialog to the Note Type field in the Document Editor tab panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-214-2	Upon submitting a document as an Add Note to the selected encounter, the system shall default the Note Category field in the Encounter Note dialog to the Specialty field in the Document Editor tab panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-214-3	Upon submitting a document as an Add Note to the selected encounter, the system shall default the Note Added field in the Encounter Note dialog to the Original Date of Document field in the Document Editor tab panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-214-4	Upon submitting a document as an Add Note to the selected encounter, the system shall default the By field in the Encounter Note dialog to the user submitting the document from within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-214-5	Upon submitting a document as an Add Note to the selected encounter, the system shall default the Note Title field in the Encounter Note dialog to the Note Title field in the Document Editor tab panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-216	When the user selects "Save Draft" the system shall save the changes the user has made.	Applicable	Not Applicable	Not Applicable
New DE-216-1	Upon selecting the “Save Draft” button on the Document Editor tab, the system shall update the document Status to “Saved”.	Applicable	Not Applicable	Not Applicable
New DE-217	The system shall allow the user to remove a document from the Document Engine database by selecting the "Delete" button.	Applicable	Not Applicable	Not Applicable
CFR18345-1	The system shall allow users who do not have signature authority to forward a document to a Provider or other authorized signer selected from a "Provider Search" screen by selecting the "Forward" button. Clarification: When the "Forward" button is selected the system shall display a "Provider Search" screen where the user can search for a Provider by last name within the MTF.	Applicable	Not Applicable	Not Applicable
CFR18345-2	Upon the user forwarding a document from the Document Editor tab, the system shall remove the document from the user’s Documents Inbox.	Applicable	Not Applicable	Not Applicable
CFR18345-3	The system shall display a forwarded document in the Documents Inbox of the user it was forwarded to, with a status of Forwarded.	Applicable	Not Applicable	Not Applicable
CFR18345-4	The system shall allow users with signature authority to reassign a document to another Provider for review or signature by selecting the "Reassign" button. Clarification: This option shall be disabled (grayed out) if the user does not have signature authority.	Applicable	Not Applicable	Not Applicable
CFR18345-5	Upon the user reassigning a document from the Document Editor tab, the system shall remove the document from the user’s Documents Inbox.	Applicable	Not Applicable	Not Applicable
CFR18345-6	The system shall allow the user to return a forwarded document to the user that forwarded it for clarification/revision by selecting the "Return for Revision" button.	Applicable	Not Applicable	Not Applicable
CFR18345-7	Upon the user returning a document for clarification/revision from the Document Editor tab, the system shall remove the document from the user’s Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-308 MAPS to CFR15401 CFR18335 CFR18336 CFR15190 CFR15400 CFR18351	Upon the user selecting the "Sign and Submit" button on the Document Editor tab, for a document with an “Outpatient” Patient Status and an associated encounter, the system shall import the file directly into the Add Note of the selected Encounter if it is currently in an open status (e.g., In Progress, Updating, Needs Co-Signature).	Applicable	Not Applicable	Not Applicable
New DE-309 MAPS to CFR15401 CFR18335 CFR18336 CFR15190 CFR15400 CFR18351	Upon the user selecting the "Sign and Submit" button within the Document Editor tab, for a document with an “Outpatient” Patient Status and an associated encounter the system shall update the encounter by adding the captured file as an Appended Note for the selected Encounter if it is currently in a closed status (e.g., Complete, Updated, and Admin Closed). Business Rule: The Sign Appended Note dialog within the Encounter module will not be displayed for the provider to sign the appended note since the provider previously signed the document in the document engine.	Applicable	Not Applicable	Not Applicable
New DE-309-1	Upon the user selecting the "Sign and Submit" button within the Document Editor tab, for a document with an “Inpatient” Patient Status, the system shall change the document status to Signed.	Applicable	Not Applicable	Not Applicable
New DE-309-1.1 MAPS to CFR15401 CFR18335 CFR18336 CFR15190 CFR15400	Upon the user selecting the "Sign and Submit" button within the Document Editor tab, for a document with an “Inpatient” Patient Status and a Note Type of Consults, Operative Report, Narrative Summary, or Procedure Report, the system shall send the document to the CDR for inclusion into the Clinical Notes module. Clarification: Only these 4 types of Inpatient Note Types will be sent to Clinical Notes as well as the Inpatient Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-309-2	Upon the user selecting the "Sign and Submit" button within the Document Editor tab, for a document with an “Inpatient” Patient Status, the system shall assign the document to a default “inpatient” location. Clarification: For all Inpatient Documents. Documents will display in the main/default Inpatient Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-310	Upon submitting a document as an Add Note to the selected encounter, the application shall default the Note Category field in the Encounter Note dialog to the Note Type field in the Editor tab of the Document Editor Panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-311	Upon submitting a document as an Add Note to the selected encounter, the application shall default the Note Title field in the Encounter Note dialog to the Note Title field in the Editor tab of the Document Editor Panel within the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-312	Upon the user selecting the "Sign & Submit Document" button within the Document Editor tab for a document that does not have an encounter associated to it, the system shall store the document in the patient’s Clinical Notes module.	Applicable	Not Applicable	Not Applicable
New DE-313	Upon submitting a document as a Clinical Note for the patient displayed in the Editor tab of the Documents Inbox module, the application shall default the Note Type field in the Clinical Notes module to the Note Type field in the Editor tab of the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-314	Upon submitting a document as a Clinical Note for the patient displayed in the Editor tab of the Documents Inbox module, the application shall default the Date field in the Clinical Notes module to the "Original Date of Document" field from the Editor tab of the Documents Inbox module.	Applicable	Not Applicable	Not Applicable
New DE-315	Upon submitting a document as a Clinical Note for the patient displayed in the Editor tab of the Documents Inbox module, the application shall default the Clinician field in the Clinical Notes module to the current logged in user.	Applicable	Not Applicable	Not Applicable
New DE-316	Upon submitting a document as a Clinical Note for the patient displayed in the Editor tab of the Documents Inbox module, the application shall default the POC field in the Clinical Notes module to the MTF where the user is currently logged in.	Applicable	Not Applicable	Not Applicable

3.2.4.2.2 Encounter Search Screen

Users will be able to search for a patient encounter by clicking on the Encounter Search icon to the right of the Associated Encounter text box. Upon initiating a search, the system will return the patient’s open and closed encounters for the last two months as shown in Figure 3‑31.

The following encounter metadata will be displayed:

Date: Date and time of appointment.
Clinic: The clinic associated with the appointment.
Provider Name: The provider associated with the appointment.
Status: The status of the appointment.

To select an encounter, the user must select the checkbox associated with the desired encounter prior to selecting the OK button. The system will return the user to the Editor tab, where the Associated Encounter text box will be populated with the date/time of the selected encounter and the Associated Clinic field will be populated with the clinic information of the selected encounter.

The user can also use the Cancel button to return to the Editor tab without selecting an encounter.

Return to Document Editor with no encounter selected

Return to Document Editor with new encounter selected

Figure 3‑31: Results of Encounter Search

3.2.4.2.3 Revisions Tab

The Revisions tab (see Figure 3‑32) tracks and provides change histories for the selected document. For each revision saved, the Revisions tab will display version number, date saved, modifying user, and action taken. Checkboxes allow the user to select specific revisions for the following actions:

View Version: Displays the selected document version.
Delete Version: Deletes the selected document version(s). Only versions that belong to the active user will be available for this action. Once deleted, all references to this version will be permanently removed from the DE database.
Rollback to Selected Version: Reverts to the selected document version, deleting more recent revisions. A user can select a version for rollback by selecting the checkbox associated with that version and selecting the Rollback to Selected Version button. The user can revert to a prior version, but only up to the last version that did not belong to the current user. For example: Document A was changed three times, the current version is 3.0, and the state is SAVED. When User A was in possession of the document, he made two changes, resulting in Versions 1.0 and 2.0. Then the document was forward to User B, at which point User B made more changes (Version 3.0) to the document, but was not ready to sign off. When User B accessed this document the second time, he decided to rollback the changes. Based on the rollback rule, User B can only select to rollback to Version 2.0, not to Version 1.0.

Figure 3‑32: Revisions Tab of the Document Editor Panel

Table 3‑13: Revisions Tab Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-221	When the user selects the "Revisions" tab from the "Document Editor" panel the system shall display the "Document Revision History and Management" screen. Clarification: This screen is a log of the date changes were made to the document, who the document was edited by, and the action taken.	Applicable	Not Applicable	Not Applicable
New DE-222	The system shall display the "Document Revision History and Management" screen as a table with the following columns: Selected, Version, Date, Edited By, and Action Taken.	Applicable	Not Applicable	Not Applicable
New DE-223	The system shall display the following buttons at the bottom of the "Document Revision History and Management" screen: "View Version", "Delete Version", and "Rollback to Selected Version".	Applicable	Not Applicable	Not Applicable
New DE-227	When the user checks the checkbox for a document version and selects the "Rollback to Selected Version" button the system shall revert to the selected prior version. Clarification: The user can revert to a prior version but only up to the last version that did not belong to the current user. For example: Document A was changed 3 times and is sitting at version 3 as the current version and the state is “SAVED”. When user A was in possession of the document, he made two changes resulting in versions 1 and 2. Then the document was forwarded to user B at which point user B made some more changes (version 3) to the document but was not ready to sign off. When User B accesses this document the second time, he decided to rollback the changes. Based on the rollback rule, user B can only select to rollback to version 2, not version 1.	Applicable	Not Applicable	Not Applicable
New DE-224	The system shall display a checkbox in the "Selected" column to allow the user to select the version to view.	Applicable	Not Applicable	Not Applicable
New DE-225	When the user checks the checkbox for a document version and selects the "View Version" button the system shall display the "Editor" tab reloaded with the metadata and document associated with the selected version.	Applicable	Not Applicable	Not Applicable
New DE-226	When the user checks the checkbox for a document version and selects the "Delete" button the system shall delete this version and permanently remove all references to this version from the Document Engine database. Clarification: Only document versions that belong to the user will be available for this action.	Applicable	Not Applicable	Not Applicable

3.2.4.2.4 Attachments Tab

The Attachments tab (see Figure 3‑33) allows a user to view and add additional documents to supplement the selected document (e.g., raw test data). It also displays the documents/data obtained using the CDCM. Checkboxes allow the user to select specific attachments for the following actions:

View Attachment: Displays selected attachment in its native format. For example, PDF attachments will be displayed using Adobe Reader.
Delete Selected Attachment(s): Permanently deletes selected attachment(s) from the DE database.
Load File: Uploads additional files for attachment. The Browse… button launches a window to locate the new attachment to be loaded. Load File initiates the upload.

Upload new document

Use to delete attachments selected above

Use to display selected attachment

Figure 3‑33: Attachments Tab of the Document Editor Panel

Figure 3‑34 below displays an attachment in its native PDF format.

Figure 3‑34: Rendering a PDF Attachment

Table 3‑14: Attachments Tab Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-228	When the user selects the "Attachments" tab from the "Document Editor" panel the system shall display the "Attachments" screen.	Applicable	Not Applicable	Not Applicable
New DE-229	The system shall display the "Attachments" screen as a table with the following columns: Select, Date, Description, Type, and Service.	Applicable	Not Applicable	Not Applicable
New DE-230	The system shall display the following at the bottom of the "Attachments" screen: "View Attachment" button, "Delete Selected Attachment(s)" button, "Attach File from File System" text box with "Browse" button, and "Load File" button.	Applicable	Not Applicable	Not Applicable
New DE-231	The system shall allow the user to view an attachment by placing a checkmark in the Select column checkbox next to the attachment to be viewed and selecting the "View Attachment" button. Clarification: Multiple selections not allowed.	Applicable	Not Applicable	Not Applicable
New DE-232	The system shall display the selected attachment in its native format when the user selects the "View Attachment" button.	Applicable	Not Applicable	Not Applicable
New DE-232-1	When the user selects the View Attachment button the system shall display an error message if the document size exceeds maximum size limit of 500K. Clarification: The user will be able to select an option from the message displayed below: <<...OLE_Obj...>> a. Store in DE: Document is signed and kept in user's DE inbox with status of “SIGNED”. User is then returned to the Documents Inbox screen. b. Print & Delete: Document is signed and user can obtain a printed copy to add it to patient's paper charts. Afterwards, user is then returned to Documents Inbox screen. Document will be purged from DE. c. Cancel: Document will not be signed and user is returned to Document Editor Tab screen.
New DE-233	The system shall allow the user to delete one ore more attachments by placing a checkmark in the Select column checkbox(es) next to the attachment(s) to be deleted and selecting the "Delete Selected Attachment(s)" button.	Applicable	Not Applicable	Not Applicable
New DE-233-1	Upon the user selecting the “Delete Selected Attachment(s)” button, the system shall permanently delete the attachment(s) from the Document Engine database.	Applicable	Not Applicable	Not Applicable
New DE-234	The system shall allow the user to add a new attachment by entering the file name in the "Attach File from File System" textbox and selecting the "Load File" button.	Applicable	Not Applicable	Not Applicable
New DE-234-1	The system shall allow the user to search for a file to add to the document from the Attachments tab. Clarification: via the Browse button.	Applicable	Not Applicable	Not Applicable
New DE-234-2	Upon selecting the Browse button on the Attachments tab of the Document Editor panel, the system shall display the Select Destination File screen.	Applicable	Not Applicable	Not Applicable
New DE-234-3	Upon selecting a file to attach to the document from the Select Destination File screen, the system shall return the user to the Attachments tab and populate the Attach File from File System field with the name of the selected file.	Applicable	Not Applicable	Not Applicable

3.2.4.2.5 Documents Viewer Panel

When a user selects a document from the Inpatient Documents Inbox, the system displays the Document Viewer panel (Figure 3‑35) to the right of the Inpatient Documents Inbox panel, enabling the user to preview a document.

The following controls are available on the Document Viewer panel:

Cancel: Exits out of the Document Viewer.
First Page: Navigates to the first page of the document.
Last Page: Navigates to the last page of the document.
Previous Page: Navigates to the previous page.
Next Page: Navigates to the next page.

Documents Inbox Panel

Document Viewer Panel

Use to exit from document viewer

Document 100265 is selected for viewing

Use to navigate to next page

Use to navigate to last page of document

Use to navigate to first page of document

Use to navigate to previous page

Figure 3‑35: Document Selected for Preview

Table 3‑15: Inpatient Documents Inbox Viewer Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
New DE-234-4	Upon the user selecting a document from the Inpatient Documents Inbox, the system shall display the Document Viewer panel to the right of the Inpatient Documents Inbox.	Applicable	Not Applicable	Not Applicable
New DE-234-5	The Document Viewer shall have two sections; the Document navigation controls and the document viewing section.	Applicable	Not Applicable	Not Applicable
New DE-234-6	The Document Viewers navigation control allows the user to move to the document’s first page.	Applicable	Not Applicable	Not Applicable
New DE-234-7	The Document Viewers navigation control allows the user to move to the document’s next page.	Applicable	Not Applicable	Not Applicable
New DE-234-8	The Document Viewers navigation control allows the user to move to the document’s Last page.	Applicable	Not Applicable	Not Applicable
New DE-234-9	The Document Viewers navigation control allows the user to move to the document’s previous page.	Applicable	Not Applicable	Not Applicable
New DE-234-10	The system shall allow the user to exit the Document Viewer panel. Clarification: via the Cancel button.	Applicable	Not Applicable	Not Applicable
New DE-234-11	The system shall display the contents of the document selected in the Inpatient Documents Inbox in the Document Viewer. Clarification: In the viewing section. This content is NOT editable.	Applicable	Not Applicable	Not Applicable
CFR15193	The system shall not be required to extract any clinical content from these text transcription documents for use in any reports, wellness, surveillance, or E&M calculation.	Applicable	Not Applicable	Not Applicable

3.2.5 CSCI Requirements

The requirements associated with the DE Integration project can be found in a complete listing in Appendix A. The appendix lists the software unit reference number, software unit designation, Polytron Version Control System (PVCS) Tracker number, Dynamic Object Oriented Requirement System (DOORS) number, and the requirement description. The details as required by the Data Item Description (DID) have been incorporated into the detailed listing of the requirements within Appendix A.

3.2.6 Physical Network Design

Refer to Figure 1-1 for the Physical Network design for the DE project.

3.2.7 Logical Data Flow

N/A

3.2.8 Logical Data Flow—Training Module

N/A

3.3 CSCI External Interface Requirements

The priority assigned by the CSCI for the external interface(s) identified within the following subsections will always be a priority of 1 since the implementation of the functionality required by this project will not be possible without the operability of each interface. As such, the paragraph(s) in the following subsection(s) required by the DID indicating the priority assigned for the interface has (have) been tailored out.

3.3.1 Interface ID and Diagrams

All interface decisions are left to the technical design.

3.3.2 Project-unique Identifier of Interface

All interface decisions are left to the technical design.

3.4 CSCI Internal Interface Requirements

All internal interface decisions are left to the technical design.

3.5 CSCI Internal Data Requirements

The internal data are left to the design.

3.6 Adaptation Requirements

N/A

3.7 Safety Requirements

N/A

3.8 Security and Privacy Requirements

AHLTA is currently accredited by MHS as a Mission Assurance Category II (MAC II) Confidentiality Level Sensitive system. DoD Instruction 8500.2 lists the applicable security requirements that were used for the accreditation effort. As a DoD Information Technology Security Certification and Accreditation Process (DITSCAP) accredited system, all changes including software functionality and hardware architecture must be configured and tested to ensure that the “as accredited” security model and risk level are maintained in accordance with the AHLTA System Security Authorization Agreement.

3.8.1 Security Requirements

This subsection describes the security-related requirements for the project.

3.8.1.1 Security Matrix Objects

A security matrix object must be created called "DOCUMENT_CAPTURE".

A security matrix object must be created called "DOCUMENT_INBOX".

A security matrix object must be created called "DOCUMENT_INBOX_INPATIENT".

3.8.1.2 Security Matrix Keys

A new key called "DOCUMENT_CAPTURE" in the Special Documentation Tools category will be created for the new security matrix DOCUMENT_CAPTURE object.

A new key called "DOCUMENT_INBOX" in the Special Documentation Tools category will be created for the new security matrix DOCUMENT_INBOX object.

A new key called "DOCUMENT_INBOX_INPATIENT" in the Special Documentation Tools category will be created for the new security matrix DOCUMENT_INBOX_INPATIENT object.

3.8.1.3 Administrator or Enterprise Functions

The system will provide a method for the application to look up in AHLTA whether a user has a specific security privilege. The lookup will be by user NCID and the Privilege Area in question.

3.8.2 Privacy Requirements

There are no new or alterations to existing privacy requirements necessary for this project.

NOTE: The MTF database administrator will be responsible for assigning security keys and ensuring that printers meet Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy requirements.

3.9 CSCI Environment Requirements

N/A

3.10 Computer Resource Requirements

This section describes the computer resource requirements for this project.

3.10.1 Computer Hardware Requirements

The following is the recommended minimum configuration of the DES, based on the current configuration in use at the Naval Medical Center in San Diego.

Figure 3‑36: DE Server Recommended Minimum Configuration

In order for the DES to comply with DoD security requirements, other software components might be included outside of the above list.

3.10.2 Computer Hardware Resource Utilization Requirements

Questions have been raised as to whether the DE application and its components could be deployed within the existing LCS to eliminate the need for a new hardware asset. The DE will involve significant data streaming from the Document Capture module, and significant inbound/outbound HL7 traffic from the CDR and TS to the HL7 Engine.

Given the critical nature of the LCS performance, which could be compromised by server load from the DE, it is recommended that the DE application and components use dedicated servers. This document will assume that the DE will run on a new server to be added to the baseline AHLTA/MTF hardware. Its operations are dependent on the LCS; hence, both servers must be deployed together.

3.10.3 Computer Software Requirements

Rather than set up a separate Oracle database for use by the DE system, the Oracle 10g database residing on the LCS should be used to host both the DE and HL7 schemas.

If there is currently not an MHS Enterprise license for the Red Hat 4.0 Linux AS operating system, a license must be purchased for each facility where the DES is located.

3.10.4 Computer Communications Requirements

There are no new alterations to existing communications requirements for this project.

3.11 Software Quality Factors

There are no new or alterations to existing software quality factors for this project.

3.11.1 Functionality

To ensure that the requirements function as designed, the exit criteria detailed below must be achieved before this project can be recommended for release to the Development, Test, and Evaluation (DT&E) team:

The approved requirements are passing.
All priority 1 and priority 2 errors from System Test must be fixed, tested, and passed.
If any medium or low priority (3 through 5) errors are left outstanding, the implementation risk must be approved as acceptable by the Northrop Grumman Release Manager.
The test scenarios can be executed without producing any errors.

Priority levels are defined as follows:

Priority 1

Errors that prevent a System Test of a particular function from continuing, or data type error.
Errors that prevent the accomplishment of an operational capability specified by baseline requirements.
Errors that prevent the operator’s accomplishment of an operational or mission-essential capability specified by baseline requirements.
Incorrect data is passed to CHCS, resulting in corruption or system crash.
The defect results in the failure of the complete software system, a subsystem, or a software unit (program or module) within the system.
Any error that would affect patient safety.

Priority 2

The defect results in the failure of the complete software system, a subsystem, or a software unit (program or module) within the system. There is no way to make the failed component(s) work; however, there are acceptable processing alternatives that will yield the desired result.
An error adversely affects the operator’s accomplishment of an operational or mission-essential capability specified by baseline requirements. This type of error degrades performance and possesses no known alternative workaround solution.

Priority 3

Serious or missing data-related errors that will not prevent implementation.
The defect does not result in a failure, but causes the system to produce incorrect, incomplete, or inconsistent results; or the defect impairs the system’s usability.
A less important element of functionality is affected.
Data is affected that does not have a major impact on AHLTA.
There is an alternative method of completing a particular process (i.e., a problem might occur when reading all of the details of an update; this change can be input manually).

Priority 4

The defect does not cause a failure, does not impair usability, and the desired processing results are easily obtained by working around the defect.
Problems that are an operator inconvenience or annoyance and that do not affect a required operational or mission-essential capability.

Priority 5

The defect that is the result of non-conformance to a standard, is related to the aesthetics of the system, or is a request for an enhancement. Defects at this level may be deferred or not addressed.
Errors that are minor and do not prevent or hinder functionality.
Incorrect or no help text on screens.
Drop-down lists repeat an option.
All other problems/changes.

3.11.2 Reliability

The DE Integration project will allow the system to receive dictations from external transcriptions systems as well as capture and store data from legacy equipment and Windows applications.

3.11.3 Maintainability

The AHLTA code changes required for this project will be performed within the existing code baselines to ensure ease of maintainability.

3.11.4 Availability

This project will not affect the availability of AHLTA.

3.11.5 Flexibility

The DE Integration project will allow the system to receive transcribed documents from external transcriptions systems and provide the user with the ability to edit the received documents before signing and submitting as a permanent record in the patient’s chart.

3.11.6 Portability

N/A

3.11.7 Reusability

N/A

3.11.8 Testability

The requirements that have been developed for this project are testable and can be quantified by the Northrop Grumman IT test team and the DT&E test team.

3.11.9 Usability

The changes that will be implemented in the DE Integration project will be intuitive and easy for the end user to access. The change to the module is limited and will not have a major training impact on the user. There should be a smooth transition to the functionality being added.

3.12 Design and Implementation Constraints

This project will be constrained to the existing system architecture, development languages and tools, and, to a great extent, the existing code base, which is being modified for the current purposes.

All functionality and data introduced in this project may have an impact on the Patient and Provider Merge processes. This includes possible impact on patient or provider data being merged or on the process to determine whether or not two patient or two provider records should be merged. The patient and provider merge issues will be addressed in a later phase and will be handled on a case-by-case basis with manual substitution for the initial release.

3.13 Personnel-related Requirements

There are no new or alterations to existing personnel-related requirements for this project.

3.14 Training-related Requirements

The training for the DE Integration project will be provided in the AHLTA training classes, including written materials. The AHLTA help file in the program will also be updated. There will also be implementation assistance on-site to answer questions when AHLTA is first implemented at a site. AHLTA Sustainment support and Super Users can also be used as resources for training purposes and questions.

3.15 Logistics-related Requirements

System maintenance and software support will be provided in accordance with the Warranty Section 9.8 of the SOW for this project. No impact on existing facilities or equipment is anticipated by the implementation and delivery of this CSCI. The equipment to operate the CSCI is expected to meet the requirements and specifications that are outlined in sections 3.9 and 3.10.

3.16 Other Requirements

None.

3.17 Packaging Requirements

The DE Integration changes will be wrapped into a build and will be delivered to DT&E as a scheduled deliverable. The enhancements conducted during this project may or may not be combined with other features that are being delivered at the same time. The exact determination of what will be included in the build will be identified prior to the Test Readiness Review 1 (TRR1) and the resultant delivery to DT&E.

3.18 Precedence and Criticality of Requirements

All requirements have equal weight.

4. Qualification Provisions

There are no special tools, test equipment, or analysis of accumulated data that will need to be extrapolated to ensure that the requirements have been met. All of the requirements identified in Appendix A will use the Demonstration method to ensure that the requirement has been met.

.

5. Requirements Traceability

IMPORTANT: The Northrop Grumman IT Systems Analysis team works with Information Management (IM) to establish and approve requirements. Northrop Grumman IT requests that a DOORS ID be assigned by IM to each requirement; however, IM does not always provide Northrop Grumman IT with a DOORS ID to link to each requirement. When this occurs, the RTM attached in Appendix A will not include any DOORS IDs. If Northrop Grumman IT has received a DOORS ID for a requirement, it is included in the RTM.

5.1 Current Build

The traceability from each software unit to the requirements can be seen in the Current Build tab in the embedded requirements in Appendix A. This tab also contains the mapping to the IM functional requirements.

5.2 Action Items

The traceability from each software unit to the requirements can be seen in the Current Build tab in the embedded requirements in Appendix A. This tab also contains the mapping to the IM functional requirements.

5.3 Phase 2

All IM requirements that cannot be implemented with the initial release of the DE are listed in the Phase 2 tab.

5.4 Unaddressed IM Requirements

All IM requirements that have not been mapped to a Current Build requirement are listed in this tab because they either need to be rewritten or deleted by IM.

6. Notes

Table 6-1 below is a listing of the acronyms contained in this document.

Table 6‑1: Acronyms

Acronym	Definition
API	Application Programming Interface
ARM	Application Response Measurement
B2B	Business-to-Business
CDCM	Clinical Data Capture Module
CDR	Clinical Data Repository
CDRL	Contract Data Requirements List
CHCS II-Theater	Composite Health Care System II-Theater
CITPO	Clinical Information Technology Program Office
CSCI	Computer Software Configuration Item
DE	Document Engine
DES	Document Engine Server
DEM	Document Engine Module
DFI	Document, File, and Image
DID	Data Item Description
DIM	Documents Inbox Module
DISA	Defense Information Systems Agency
DITSCAP	DoD Information Technology Security Certification and Accreditation Process
DO	Delivery Order
DoD	Department of Defense
DOORS	Dynamic Object Oriented Requirements System
DT&E	Development, Test, and Evaluation
E&M	Evaluation and Management
EKG	Electrocardiogram
FMP	Family Member Prefix
GOTS	Government Off-the-Shelf
HIPAA	Health Insurance Portability and Accountability Act of 1996
HL7	Health Level Seven
HTTP	Hypertext Transfer Protocol
ICD	Inline Cache Database
ICU	Intensive Care Unit
ID	Identification
IE	Interface Engine
IEN	Internal Entry Number
IM	Information Management
IRS	Interface Requirements Specification
IT	Information Technology
J2EE	Java 2 Enterprise Edition
JDBC	Java DataBase Connectivity
KB	Kilobyte
LCS	Local Cache Server
MAC II	Mission Assurance Category II
MHS	Military Health System
MTF	Military Treatment Facility
NCID	Numeric Concept ID
OC4J	Oracle Containers for J2EE
ORD	Operational Requirements Document
PDF	Portable Document Format
PFT	Pulmonary Function Test
PGUI	Provider Graphical User Interface
POC	Point of Contact
PVCS	Polytron Version Control System
RTF	Rich Text Format
RTM	Requirements Traceability Matrix
SOW	Statement of Work
SQL	Structured Query Language
SRS	Software Requirements Specification
SRTS II	Spectacle Request Transmission System II
SSN	Social Security Number
TIFF	Tagged Image File Format
TIMPO	Tri-Service Infrastructure Management Program Office
TRR1	Test Readiness Review 1
TS	Transcription System
XML	eXtensible Markup Language

Appendices

Appendix A: Requirements Traceability Matrix

Appendix B: Functional Requirements

ID	Requirement	Mode: Normal?	Mode: Training?	Mode: Failover?
CFR15190	The system shall enable the incorporation of transcription text documents from an external dictation system.	Applicable	Not Applicable	Not Applicable
CFR15191	Text documents transcribed by and imported from external dictation systems shall be automatically incorporated into the patient's CHCS II (AHLTA) electronic medical record for which the specific document references.	Applicable	Not Applicable	Not Applicable
CFR15193	The system shall not be required to extract any clinical content from these text transcription documents for use in any reports, wellness, surveillance, or E&M calculation.	Applicable	Not Applicable	Not Applicable
CFR15400	The CHCS II (AHLTA) system shall store text transcriptions for patients in the CDR on an ongoing basis.	Applicable	Not Applicable	Not Applicable
CFR15401	The CHCS II (AHLTA) system shall enable authorized users to view text transcriptions for patients.	Applicable	Not Applicable	Not Applicable
CFR18333	The system shall alert the originating provider when newly transcribed reports are received and associated with an encounter.	Applicable	Not Applicable	Not Applicable
CFR18334	The originating provider shall be able to edit the content (add characters and delete characters) of documents that are received from transcription services but have not been electronically signed.	Applicable	Not Applicable	Not Applicable
CFR18335	The originating provider shall be able to electronically sign documents that are received from transcription services.	Applicable	Not Applicable	Not Applicable
CFR18336	Once the originating provider has electronically signed the document received from transcription services, that document shall be saved as "final" and available for other authorized users to view.	Applicable	Not Applicable	Not Applicable
CFR18337	The originating provider shall have the ability to flag a transcribed document as requiring an electronic co-signature.	Applicable	Not Applicable	Not Applicable
CFR18338	Transcribed documents flagged by the originating provider for co-signature shall not be designated as final until they are co-signed.	Applicable	Not Applicable	Not Applicable
CFR18339	The originating provider shall be required to identify the provider / user that needs to review and electronically co-sign the transcribed document.	Applicable	Not Applicable	Not Applicable
CFR18340	The system shall alert the designated co-signer / user of transcribed reports that need to be signed.	Applicable	Not Applicable	Not Applicable
CFR18341	The designated co-sign provider shall be able to edit the content (add characters and delete characters) of the transcribed document before cosigning.	Applicable	Not Applicable	Not Applicable
CFR18342	Once the co-sign provider has electronically signed the transcribed document it shall be saved as "final" and available for other authorized users to view.	Applicable	Not Applicable	Not Applicable
CFR18343	Only the originating provider or the designated co-signer provider shall be able to delete a transcribed report prior to signing it however they will be required to provide a reason for the deletion which will be archived in the system's audit trail.	Applicable	Not Applicable	Not Applicable
CFR18344	Only the originating provider or the designated co-signer shall be able to append a transcribed report after signing it, however they will be required to provide a reason for the appended report which will be archived in the system's audit trail.	Applicable	Not Applicable	Not Applicable
CFR18345	An authorized user shall be able to transfer unsigned transcribed documents to another provider/user to electronically sign in the event the originating provider is no longer available to sign his/her dictated reports.	Applicable	Not Applicable	Not Applicable
CFR18346	The system audit trail shall capture the date and time a transcribed document was received by the system.	Applicable	Not Applicable	Not Applicable
CFR18347	The system audit trail shall capture the date and time a transcribed document was electronically signed by the originating provider.	Applicable	Not Applicable	Not Applicable
CFR18348	The system audit trail shall capture the date and time a transcribed document was flagged for co-signature by the originating provider.	Applicable	Not Applicable	Not Applicable
CFR18349	The system audit trail shall capture the date and time a transcribed document was electronically co-signed by the designated provider.	Applicable	Not Applicable	Not Applicable
CFR18350	The system audit trail shall capture the date and time a transcribed document was transferred to a non-originating provider for signature.	Applicable	Not Applicable	Not Applicable
CFR18351	"Final" / electronically signed transcribed documents with an encounter number shall be filed in AHLTA under "Add Note."	Applicable	Not Applicable	Not Applicable
CFR18352	"Final" / electronically signed transcribed documents without an encounter number shall be filed in AHLTA under "Clinical Note."	Applicable	Not Applicable	Not Applicable
CFR18353	The transcribed report shall have a header that clearly identifies the patient, the provider, and the date of the encounter.	Applicable	Not Applicable	Not Applicable
CFR18354	The transcribed report shall have a header that clearly identifies the type of report.	Applicable	Not Applicable	Not Applicable
CFR18355	The date and time the transcriptionist created the document shall display on the report	Applicable	Not Applicable	Not Applicable
CFR18356	The name of the transcriptionist who created the document shall display on the report	Applicable	Not Applicable	Not Applicable
CFR18357	The system user shall be able to print on demand any transcribed report.	Applicable	Not Applicable	Not Applicable
CFR18358	The system user shall be able to identify on the print out of the transcribed report the name of the individual who printed the document, along with the date and time that the document was printed.	Applicable	Not Applicable	Not Applicable
CFR18359	The report header identifying the patient, the originating provider, the date of the encounter and the type of report shall appear on all the pages of the printed transcribed report.	Applicable	Not Applicable	Not Applicable
CFR18360	The name of the transcriptionist shall appear on the printed transcribed report.	Applicable	Not Applicable	Not Applicable
CFR18361	The name of the signing provider shall appear on the printed transcribed report.	Applicable	Not Applicable	Not Applicable
CFR18362	The name of the co-signing provider shall appear on the printed transcribed report.	Applicable	Not Applicable	Not Applicable
CFR18363	In the event a transcribed report is printed that has been electronically signed the report shall include in the header the status of “Final.”	Applicable	Not Applicable	Not Applicable
CFR18364	In the event a transcribed report is printed that has not been electronically signed the report shall include in the header the status of “Not Final.”	Applicable	Not Applicable	Not Applicable
CFR18365	In the event an appended transcribed report is printed, the appendix shall print out as part of the original report which will clearly indicate the date and time the appendix was added to the report, and the name of the provider.	Applicable	Not Applicable	Not Applicable
CFR18366	The authorized system user shall be able to compile and print or export to Excel a list of transcribed reports that have not been electronically signed by the originating provider.	Applicable	Not Applicable	Not Applicable
CFR18367	The authorized system user shall be able to compile and print or export to Excel a list of transcribed reports that have not been electronically signed by a designated co-signer.	Applicable	Not Applicable	Not Applicable
CFR18368	The authorized system user shall be able to compile and print or export to Excel a list of transcribed reports that have been transferred to a provider by have not been electronically signed by that provider.	Applicable	Not Applicable	Not Applicable
CFR18369	The authorized system user shall be able to compile and print or export to Excel a list of transcribed reports that were deleted along with the name of the originating provider or co-signer provider and the reason the report was deleted.	Applicable	Not Applicable	Not Applicable
CFR18370	The authorized system user shall be able to compile, and print or export to Excel all transcribed reports that came across the interface but were rejected by AHLTA because the header file did not match an existing patient record.	Applicable	Not Applicable	Not Applicable

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