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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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:Requirements ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "EHRSFMR2-CP.8.1"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction>     ] )
      ] ; #
      fhir:language [ fhir:v "en"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<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>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "normative"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "ehr"     ]
      ] ) ; #
      fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.8.1"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.8.1>
      ] ; #
      fhir:version [ fhir:v "2.1.1"] ; #
      fhir:name [ fhir:v "CP_8_1_Generate__Record_and_Distribute_Patient_Specific_Instructions"] ; #
      fhir:title [ fhir:v "CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function)"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:date [ fhir:v "2025-12-13T09:06:06+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Electronic Health Records"] ; #
      fhir:contact ( [
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/ehr" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements."] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://unstats.un.org/unsd/methods/m49/m49.htm"^^xsd:anyURI ;
    fhir:l <http://unstats.un.org/unsd/methods/m49/m49.htm>       ] ;
    fhir:code [ fhir:v "001" ] ;
    fhir:display [ fhir:v "World" ]     ] )
      ] ) ; #
      fhir:purpose [ fhir:v "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)."] ; #
      fhir:statement ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-01" ] ;
    fhir:label [ fhir:v "CP.8.1#01" ] ;
        ( fhir:conformance [ fhir:v "SHALL" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHALL provide the ability to determine and render standardized instruction sets pertinent to the patient condition, for procedures, or scheduled events." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#1" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-02" ] ;
    fhir:label [ fhir:v "CP.8.1#02" ] ;
        ( fhir:conformance [ fhir:v "SHALL" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#2" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-03" ] ;
    fhir:label [ fhir:v "CP.8.1#03" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#3" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-04" ] ;
    fhir:label [ fhir:v "CP.8.1#04" ] ;
        ( fhir:conformance [ fhir:v "SHALL" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "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." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#4" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-05" ] ;
    fhir:label [ fhir:v "CP.8.1#05" ] ;
        ( fhir:conformance [ fhir:v "SHALL" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHALL provide the ability to capture an indication that instructions were given to the patient." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#5" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-06" ] ;
    fhir:label [ fhir:v "CP.8.1#06" ] ;
        ( fhir:conformance [ fhir:v "SHALL" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "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." ] ;
    fhir:derivedFrom [ fhir:v "EHR-S_FM_R1.1 DC.1.9#6" ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-07" ] ;
    fhir:label [ fhir:v "CP.8.1#07" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHOULD provide the ability to annotate patient-specific instructions." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-08" ] ;
    fhir:label [ fhir:v "CP.8.1#08" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "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." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-09" ] ;
    fhir:label [ fhir:v "CP.8.1#09" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHOULD provide the ability to manage patient instructions in multiple languages." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-10" ] ;
    fhir:label [ fhir:v "CP.8.1#10" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to manage a list of appropriate patient instructions based on age." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-11" ] ;
    fhir:label [ fhir:v "CP.8.1#11" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to manage a list of appropriate patient instructions based on gender." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-12" ] ;
    fhir:label [ fhir:v "CP.8.1#12" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-13" ] ;
    fhir:label [ fhir:v "CP.8.1#13" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level." ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent>       ] ;
    fhir:value [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:key [ fhir:v "EHRSFMR2-CP.8.1-14" ] ;
    fhir:label [ fhir:v "CP.8.1#14" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to render educational materials using alternative modes to accommodate patient sensory capabilities (e.g., vision impairment, hearing impairment)." ]
      ] ) . #