HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1 - Normative

HL7 Electronic Health Record System Functional Model, Release 2.1.1, published by HL7 International / Electronic Health Records. This guide is not an authorized publication; it is the continuous build for version 2.1.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ehrsfm-ig/ and changes regularly. See the Directory of published versions

## : CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function)

Page standards status: Normative

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    {
      "resourceType" : "Requirements",
      "id" : "EHRSFMR2-CP.8.1",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"
        ]
      },
      "language" : "en",
      "text" : {
        "status" : "extensions",
        "div" : "<div xml:lang=\"en\" xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en\">\n    \n    \n    <div id=\"description\"><b>Description <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Informative Content\" class=\"informative-flag\">I</a>:</b> <div><p>When a patient is scheduled for a test, procedure, or discharge, specific instructions about diet, clothing, transportation assistance, convalescence, follow-up with physician, etc., may be generated and recorded, including the timing relative to the scheduled event. In an outpatient scenario, similar instructions for post-diagnosis, and/or post-treatment needs may also be generated and recorded (e.g., exercise instructions for low back pain, wound or burn care).</p>\n</div></div>\n    \n    \n    \n    <div id=\"requirements\"><b>Criteria <a href=\"https://hl7.org/fhir/versions.html#std-process\" title=\"Normative Content\" class=\"normative-flag\">N</a>:</b></div>\n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#01\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHALL\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHALL provide the ability to determine and render standardized instruction sets pertinent to the patient condition, for procedures, or scheduled events.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#02\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHALL\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#03\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHOULD\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#04\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHALL\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHALL provide the ability to render as part of patient instructions details on further care such as follow up, return visits and appropriate timing of further care.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#05\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHALL\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHALL provide the ability to capture an indication that instructions were given to the patient.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#06\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHALL\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHALL provide the ability to capture the actual instructions given to the patient or a reference to the document(s) containing those instructions.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#07\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHOULD\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHOULD provide the ability to annotate patient-specific instructions.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#08\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHOULD\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHOULD provide the ability to capture and maintain, as discrete data, the reason for variation from rule-based clinical messages and patient information.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#09\n            </td>\n            <td style=\"padding-left: 4px;\">\n            SHOULD\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system SHOULD provide the ability to manage patient instructions in multiple languages.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#10\n            </td>\n            <td style=\"padding-left: 4px;\">\n            MAY\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on age.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#11\n            </td>\n            <td style=\"padding-left: 4px;\">\n            MAY\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on gender.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#12\n            </td>\n            <td style=\"padding-left: 4px;\">\n            MAY\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#13\n            </td>\n            <td style=\"padding-left: 4px;\">\n            MAY\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            CP.8.1#14\n            </td>\n            <td style=\"padding-left: 4px;\">\n            MAY\n            \n                \n            \n            \n            \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                <div><p>The system MAY provide the ability to render educational materials using alternative modes to accommodate patient sensory capabilities (e.g., vision impairment, hearing impairment).</p>\n</div>\n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
          "valueCode" : "normative"
        },
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "ehr"
        }
      ],
      "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.8.1",
      "version" : "2.1.1",
      "name" : "CP_8_1_Generate__Record_and_Distribute_Patient_Specific_Instructions",
      "title" : "CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function)",
      "status" : "active",
      "date" : "2025-12-13T09:06:06+00:00",
      "publisher" : "HL7 International / Electronic Health Records",
      "contact" : [
        {
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/ehr"
            }
          ]
        }
      ],
      "description" : "Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements.",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
              "code" : "001",
              "display" : "World"
            }
          ]
        }
      ],
      "purpose" : "When a patient is scheduled for a test, procedure, or discharge, specific instructions about diet, clothing, transportation assistance, convalescence, follow-up with physician, etc., may be generated and recorded, including the timing relative to the scheduled event. In an outpatient scenario, similar instructions for post-diagnosis, and/or post-treatment needs may also be generated and recorded (e.g., exercise instructions for low back pain, wound or burn care).",
      "statement" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-01",
          "label" : "CP.8.1#01",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to determine and render standardized instruction sets pertinent to the patient condition, for procedures, or scheduled events.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#1"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-02",
          "label" : "CP.8.1#02",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#2"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-03",
          "label" : "CP.8.1#03",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#3"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-04",
          "label" : "CP.8.1#04",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to render as part of patient instructions details on further care such as follow up, return visits and appropriate timing of further care.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#4"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-05",
          "label" : "CP.8.1#05",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture an indication that instructions were given to the patient.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#5"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-06",
          "label" : "CP.8.1#06",
          "conformance" : [
            "SHALL"
          ],
          "conditionality" : false,
          "requirement" : "The system SHALL provide the ability to capture the actual instructions given to the patient or a reference to the document(s) containing those instructions.",
          "derivedFrom" : "EHR-S_FM_R1.1 DC.1.9#6"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-07",
          "label" : "CP.8.1#07",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to annotate patient-specific instructions."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-08",
          "label" : "CP.8.1#08",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to capture and maintain, as discrete data, the reason for variation from rule-based clinical messages and patient information."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-09",
          "label" : "CP.8.1#09",
          "conformance" : [
            "SHOULD"
          ],
          "conditionality" : false,
          "requirement" : "The system SHOULD provide the ability to manage patient instructions in multiple languages."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-10",
          "label" : "CP.8.1#10",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage a list of appropriate patient instructions based on age."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-11",
          "label" : "CP.8.1#11",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage a list of appropriate patient instructions based on gender."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-12",
          "label" : "CP.8.1#12",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-13",
          "label" : "CP.8.1#13",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level."
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent",
              "valueBoolean" : false
            }
          ],
          "key" : "EHRSFMR2-CP.8.1-14",
          "label" : "CP.8.1#14",
          "conformance" : [
            "MAY"
          ],
          "conditionality" : false,
          "requirement" : "The system MAY provide the ability to render educational materials using alternative modes to accommodate patient sensory capabilities (e.g., vision impairment, hearing impairment)."
        }
      ]
    }