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{scrollbar:icons=false} h3. {page-info:title} This section includes the following: {toc:minlevel=4} h3. Clinical Data Forms Definition and Modeling Clinical Data Forms are the primary channel for capturing information in the healthcare and clinical domain. Forms also play a key role in information exchange and are critical to supporting interoperability in healthcare. A form differs from a document, in that a document is used to capture information, while a form defines skip patterns, validation rules, and other aspects required to capture or render information for a document. A document in this context is specifically a clinical document which represents information about a clinical activity. The document contains the specific information gained during that clinical activity and supports the broader definitions of a document. Documents can be transformed into human readable forms, and be transferred or transmitted electronically for use across different systems. Clinical data forms definition and modeling help to accomplish the following: *Define data entry forms using robust data representation.* Ultimately the data that is captured on a form is used in many ways, but that data must provide a high level of meaningful use to insure the consumer knows how the data was captured and what context it represents. In this way even a simple question on a form may result in a much more complex representation in the data. As an example, a Yes or No question on a form may result in a codified representation of an observation. *Reuse contextual representation.* Since a given form may collect data for a context that might be common to many forms, being able to reuse these elements in a way that insures contextual consistency is a must. Forms created with the form definition tool must retrieve from well defined metadata sources that provide common contexts, default values, and coded representations including value set binding. *Reuse form elements.* When defining a form element which is bound to a specific contextual representation, it should be easy to reuse that element with minimal reconfiguration. *Provide governance support.* Forms and the supporting schemas need to be versioned as well as support the governance workflows. This insures that documentation follows a consistent and planned use. h4. 5.3.1 Clinical Data Form Functions The functions of clinical data forms include the ability to: * Define model objects for reuse * Define form templates * Bind value set to data element * Provide default form delivery * Provide form data transformation Based on the use cases the key forms requirements include: * Tools and services for defining form templates * Ability to leverage models and reusable segments for defining these forms * Ability to bind terminology in the form of value sets to form controls * User friendly tools that hide the complexity of the underlying semantics The requirements listed above are derived from the following use cases: * _Electronic Health Records_ * _ONC and Other external EHR adopters_ * _Clinical Trials_ {scrollbar:icons=false} |