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

## : AS.7.5 Manage Transitions of Care and Discharged Patients (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-AS.7.5"] ; #
      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>After the completion of an encounter, a number of tasks may remain for discharge planning, patient instructions and transitions of care. There may be outstanding laboratory tests (i.e. blood cultures) radiology interpretations, or other tasks such as arrangement of home health aids (VNA), transportation or calls to the patient's primary care provider during office hours to establish follow-up. There must be a way to track and document these tasks after the conclusion of the encounter.</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            AS.7.5#01\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 post-encounter tasks (e.g., discharge planning, patient instructions, transfer activities).</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            AS.7.5#02\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 tag the patient as a transfer patient (e.g., hospital-to-hospital, birthing facility, and long-term-care-facility to hospital).</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            AS.7.5#03\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 link transfer facility demographic information to the transfer patient.</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            AS.7.5#04\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 capture the transfer mode of transportation (e.g., ambulance, airplane).</p>\n</div>\n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n            AS.7.5#05\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 capture transportation provider demographics.</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-AS.7.5"^^xsd:anyURI ;
    fhir:l <http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-AS.7.5>
      ] ; #
      fhir:version [ fhir:v "2.1.1"] ; #
      fhir:name [ fhir:v "AS_7_5_Manage_Transitions_of_Care_and_Discharged_Patients"] ; #
      fhir:title [ fhir:v "AS.7.5 Manage Transitions of Care and Discharged Patients (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 "Provide a means to manage outstanding patient issues after the encounter, for transits of care and discharge."] ; #
      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 "After the completion of an encounter, a number of tasks may remain for discharge planning, patient instructions and transitions of care. There may be outstanding laboratory tests (i.e. blood cultures) radiology interpretations, or other tasks such as arrangement of home health aids (VNA), transportation or calls to the patient's primary care provider during office hours to establish follow-up. There must be a way to track and document these tasks after the conclusion of the encounter."] ; #
      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-AS.7.5-01" ] ;
    fhir:label [ fhir:v "AS.7.5#01" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHOULD provide the ability to manage post-encounter tasks (e.g., discharge planning, patient instructions, transfer activities)." ]
      ] [
        ( 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-AS.7.5-02" ] ;
    fhir:label [ fhir:v "AS.7.5#02" ] ;
        ( fhir:conformance [ fhir:v "SHOULD" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system SHOULD provide the ability to tag the patient as a transfer patient (e.g., hospital-to-hospital, birthing facility, and long-term-care-facility to hospital)." ]
      ] [
        ( 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-AS.7.5-03" ] ;
    fhir:label [ fhir:v "AS.7.5#03" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to link transfer facility demographic information to the transfer patient." ]
      ] [
        ( 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-AS.7.5-04" ] ;
    fhir:label [ fhir:v "AS.7.5#04" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to capture the transfer mode of transportation (e.g., ambulance, airplane)." ]
      ] [
        ( 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-AS.7.5-05" ] ;
    fhir:label [ fhir:v "AS.7.5#05" ] ;
        ( fhir:conformance [ fhir:v "MAY" ] ) ;
    fhir:conditionality [ fhir:v false ] ;
    fhir:requirement [ fhir:v "The system MAY provide the ability to capture transportation provider demographics." ]
      ] ) . #