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

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

Active as of 2024-11-23
Statement N:

Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements.

 Description I:

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).

 Criteria N:
CP.8.1#01 SHALL

The system SHALL provide the ability to determine and render standardized instruction sets pertinent to the patient condition, for procedures, or scheduled events.
CP.8.1#02 SHALL

The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider.
CP.8.1#03 SHOULD

The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient.
CP.8.1#04 SHALL

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.
CP.8.1#05 SHALL

The system SHALL provide the ability to capture an indication that instructions were given to the patient.
CP.8.1#06 SHALL

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.
CP.8.1#07 SHOULD

The system SHOULD provide the ability to annotate patient-specific instructions.
CP.8.1#08 SHOULD

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.
CP.8.1#09 SHOULD

The system SHOULD provide the ability to manage patient instructions in multiple languages.
CP.8.1#10 MAY

The system MAY provide the ability to manage a list of appropriate patient instructions based on age.
CP.8.1#11 MAY

The system MAY provide the ability to manage a list of appropriate patient instructions based on gender.
CP.8.1#12 MAY

The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis.
CP.8.1#13 MAY

The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level.
CP.8.1#14 MAY

The system MAY provide the ability to render educational materials using alternative modes to accommodate patient sensory capabilities (e.g., vision impairment, hearing impairment).