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

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Requirements: CP.3.4 Manage Patient-Specific Care and Treatment Plans (Function)

Active as of 2024-11-23
Statement N:

Provide templates and forms for clinicians to use for care plans, guidelines and protocols during provision of care and care planning.

 Description I:

During the provision of care, the clinician reviews and uses templates and forms to ensure consistent quality patient care. Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items, including alerts. Information such as Order sets for care plans may arrive from an external institution and need to be approved locally before being inserted into the care plan. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.

 Criteria N:
CP.3.4#01 SHALL

The system SHALL provide the ability to manage patient-specific plans of care and treatment.
CP.3.4#02 SHALL

The system SHALL conform to function [[CP.7.1]] (Present Guidelines and Protocols for Planning Care) and provide the ability to render locally or non-locally developed templates, guidelines, and protocols for the creation of patient-specific plans of care and treatment.
CP.3.4#03 dependent SHOULD

The system SHOULD provide the ability to capture metadata regarding a patient's plan of care or treatment (e.g., authors, creation date, version history, references, local sources and non-local sources) according to scope of practice, organizational policy, and/or jurisdictional law.
CP.3.4#04 SHOULD

The system SHOULD provide the ability to link order sets with care plans.
CP.3.4#05 SHOULD

The system SHOULD provide the ability to link the care plan with condition(s) in problem lists.
CP.3.4#06 SHOULD

The system SHOULD provide the ability to determine and render order sets from care plans.
CP.3.4#07 MAY

The system MAY provide the ability to determine and render care plans from order sets.
CP.3.4#08 SHOULD

The system SHOULD provide the ability to transmit care plans and treatment plans to other care providers.
CP.3.4#09 SHOULD

The system SHOULD conform to function [[AS.5.1]] (Clinical Task Creation, Assignment and Routing) to link care plan items into the tasks assigned and routed.
CP.3.4#10 SHOULD

The system SHOULD conform to function [[AS.5.3]] (Clinical Task Linking) to link care plan items and tasks.
CP.3.4#11 SHOULD

The system SHOULD conform to function [[AS.5.4]] (Clinical Task Status Tracking) to link care plan items with tasks tracked.
CP.3.4#12 SHOULD

The system SHOULD conform to function [[CPS.4.2.2]] (Support for Patient-Specific Dosing and Warnings) to determine and render related warnings on drug dosing and interactions.
CP.3.4#13 MAY

The system MAY conform to function [[CPS.1.7.1]] (Support for Patient and Family Preferences) to improve the effectiveness of care and treatment plans.
CP.3.4#14 MAY

The system MAY provide the ability to determine and render a care plan review schedule or conference schedule.
CP.3.4#15 SHALL

The system SHALL provide the ability to capture, maintain and render, as discrete data, the reason for variation from rule-based clinical messages (e.g., alerts and reminders).
CP.3.4#16 SHOULD

The system SHOULD provide the ability to capture that a patient should not be on a generally recommended care plan and the reason why.
CP.3.4#17 SHALL

The system SHALL provide the ability to capture care processes across the continuum of care.
CP.3.4#18 SHOULD

The system SHOULD provide the ability to render care processes from across the continuum of care.
CP.3.4#19 dependent SHALL

The system SHALL provide the ability to render internal care plans, guidelines, and protocols according to scope of practice.
CP.3.4#20 dependent SHOULD

The system SHOULD provide the ability to render external care plans, guidelines, and protocols according to scope of practice, and/or organizational policy.