ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local
ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
2.1.0 - local
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| Active as of 2024-11-26 |
<Requirements xmlns="http://hl7.org/fhir">
<id value="EHRSFMR2.1-CP.4.4"/>
<meta>
<profile value="http://hl7.org/ehrs/StructureDefinition/FMFunction"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<span id="description"><b>Statement <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b> <div><p>Enable the origination, documentation, transmission, tracking and maintenance of orders for diagnostic tests.</p>
</div></span>
<span id="purpose"><b>Description <a href="https://hl7.org/fhir/versions.html#std-process" title="Informative Content" class="informative-flag">I</a>:</b> <div><p>Orders for diagnostic tests (e.g., diagnostic radiology, laboratory ) are captured and tracked including new, renewal and discontinue orders. Each order includes appropriate detail, such as order identification, instructions and clinical information necessary to perform the test. Orders and supporting detailed documentation shall be communicated to the service provider for completion of the diagnostic test(s).Some systems may contain instructions, but in some settings, instructions may be provided from external sources (e.g., handouts).</p>
</div></span>
<span id="requirements"><b>Criteria <a href="https://hl7.org/fhir/versions.html#std-process" title="Normative Content" class="normative-flag">N</a>:</b></span>
<table id="statements" class="grid dict">
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#01</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL provide the ability to manage orders for diagnostic tests.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#02</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL provide the ability to capture and render standard order detail for diagnostic test order fulfillment.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#03</span>
</td>
<td style="padding-left: 4px;">
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHOULD provide the ability to capture and maintain user-created instructions, and/or prompts when ordering diagnostic tests or procedures.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#04</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL provide the ability to manage the status (e.g., requisitioned, completed, in process) of diagnostic test(s).</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#05</span>
</td>
<td style="padding-left: 4px;">
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHOULD provide the ability to capture and render patient instructions relevant to the diagnostic test ordered.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#06</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL provide the ability to transmit orders to the recipient (s) for order fulfillment of the diagnostic test.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#07</span>
</td>
<td style="padding-left: 4px;">
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHOULD provide the ability to transmit supporting detailed documentation to the recipient (s) for order fulfillment of the diagnostic test.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#08</span>
</td>
<td style="padding-left: 4px;">
<span>SHALL</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHALL conform to function [[CPS.4.3]] (Support for Non-Medication Ordering).</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#09</span>
</td>
<td style="padding-left: 4px;">
<i>dependent</i>
<span>MAY</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system MAY provide the ability to transmit order activity to public health authorities according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#10</span>
</td>
<td style="padding-left: 4px;">
<i>conditional</i>
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>IF subsequent orders are being captured, THEN the system SHOULD provide the ability to render prior diagnostic results for a given patient.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#11</span>
</td>
<td style="padding-left: 4px;">
<i>dependent</i>
<span>SHOULD</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system SHOULD capture and render complete patient demographic information for diagnostic orders according to scope of practice, organizational policy, and/or jurisdictional law.</p>
</div></span>
</td>
</tr>
<tr>
<td style="padding-left: 4px;">
<span>CP.4.4#12</span>
</td>
<td style="padding-left: 4px;">
<span>MAY</span>
</td>
<td style="padding-left: 4px;" class="requirement">
<span><div><p>The system MAY provide the ability to capture, maintain, and render justification-related information regarding a test order (e.g., clinical rationale, reason, or a link to the Problem list).</p>
</div></span>
</td>
</tr>
</table>
</div>
</text>
<url value="http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CP.4.4"/>
<version value="2.1.0"/>
<name value="CP_4_4_Manage_Orders_for_Diagnostic_Screening_Tests"/>
<title
value="CP.4.4 Manage Orders for Diagnostic/Screening Tests (Function)"/>
<status value="active"/>
<date value="2024-11-26T16:30:50+00:00"/>
<publisher value="EHR WG"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/ehr"/>
</telecom>
</contact>
<description
value="Enable the origination, documentation, transmission, tracking and maintenance of orders for diagnostic tests."/>
<jurisdiction>
<coding>
<system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
<code value="001"/>
<display value="World"/>
</coding>
</jurisdiction>
<purpose
value="Orders for diagnostic tests (e.g., diagnostic radiology, laboratory ) are captured and tracked including new, renewal and discontinue orders. Each order includes appropriate detail, such as order identification, instructions and clinical information necessary to perform the test. Orders and supporting detailed documentation shall be communicated to the service provider for completion of the diagnostic test(s).Some systems may contain instructions, but in some settings, instructions may be provided from external sources (e.g., handouts)."/>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-01"/>
<label value="CP.4.4#01"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL provide the ability to manage orders for diagnostic tests."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#1"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-02"/>
<label value="CP.4.4#02"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL provide the ability to capture and render standard order detail for diagnostic test order fulfillment."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#2"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-03"/>
<label value="CP.4.4#03"/>
<conformance value="SHOULD"/>
<conditionality value="false"/>
<requirement
value="The system SHOULD provide the ability to capture and maintain user-created instructions, and/or prompts when ordering diagnostic tests or procedures."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-04"/>
<label value="CP.4.4#04"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL provide the ability to manage the status (e.g., requisitioned, completed, in process) of diagnostic test(s)."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#3"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-05"/>
<label value="CP.4.4#05"/>
<conformance value="SHOULD"/>
<conditionality value="false"/>
<requirement
value="The system SHOULD provide the ability to capture and render patient instructions relevant to the diagnostic test ordered."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#4"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-06"/>
<label value="CP.4.4#06"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL provide the ability to transmit orders to the recipient (s) for order fulfillment of the diagnostic test."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#5"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-07"/>
<label value="CP.4.4#07"/>
<conformance value="SHOULD"/>
<conditionality value="false"/>
<requirement
value="The system SHOULD provide the ability to transmit supporting detailed documentation to the recipient (s) for order fulfillment of the diagnostic test."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#6"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-08"/>
<label value="CP.4.4#08"/>
<conformance value="SHALL"/>
<conditionality value="false"/>
<requirement
value="The system SHALL conform to function [[CPS.4.3]] (Support for Non-Medication Ordering)."/>
<derivedFrom value="EHR-S_FM_R1.1 DC.1.7.2.2#7"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="true"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-09"/>
<label value="CP.4.4#09"/>
<conformance value="MAY"/>
<conditionality value="false"/>
<requirement
value="The system MAY provide the ability to transmit order activity to public health authorities according to scope of practice, organizational policy, and/or jurisdictional law."/>
<derivedFrom value="PHFP DC.1.7.2.2CC#8"/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-10"/>
<label value="CP.4.4#10"/>
<conformance value="SHOULD"/>
<conditionality value="true"/>
<requirement
value="IF subsequent orders are being captured, THEN the system SHOULD provide the ability to render prior diagnostic results for a given patient."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="true"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-11"/>
<label value="CP.4.4#11"/>
<conformance value="SHOULD"/>
<conditionality value="false"/>
<requirement
value="The system SHOULD capture and render complete patient demographic information for diagnostic orders according to scope of practice, organizational policy, and/or jurisdictional law."/>
</statement>
<statement>
<extension
url="http://hl7.org/ehrs/StructureDefinition/requirements-dependent">
<valueBoolean value="false"/>
</extension>
<key value="EHRSFMR2.1-CP.4.4-12"/>
<label value="CP.4.4#12"/>
<conformance value="MAY"/>
<conditionality value="false"/>
<requirement
value="The system MAY provide the ability to capture, maintain, and render justification-related information regarding a test order (e.g., clinical rationale, reason, or a link to the Problem list)."/>
</statement>
</Requirements>