ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
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: CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function) - JSON Representation

Active as of 2024-11-23

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{
  "resourceType" : "Requirements",
  "id" : "EHRSFMR2.1-CP.8.1",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/ehrs/StructureDefinition/FMFunction"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <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>Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements.</p>\n</div></span>\n\n    \n    <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>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></span>\n    \n\n    \n\n    \n    <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>\n    \n    <table id=\"statements\" class=\"grid dict\">\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#01</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><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></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#02</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#03</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#04</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><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></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#05</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHALL provide the ability to capture an indication that instructions were given to the patient.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#06</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHALL</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><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></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#07</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to annotate patient-specific instructions.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#08</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><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></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#09</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>SHOULD</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system SHOULD provide the ability to manage patient instructions in multiple languages.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#10</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on age.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#11</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on gender.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#12</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#13</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level.</p>\n</div></span>\n                \n                \n            </td>\n        </tr>\n        \n        <tr>\n            <td style=\"padding-left: 4px;\">\n                \n                <span>CP.8.1#14</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\">\n                \n                \n                \n                <span>MAY</span>\n                \n            </td>\n            <td style=\"padding-left: 4px;\" class=\"requirement\">\n                \n                <span><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></span>\n                \n                \n            </td>\n        </tr>\n        \n    </table>\n</div>"
  },
  "url" : "http://hl7.org/ehrs/Requirements/EHRSFMR2.1-CP.8.1",
  "version" : "2.1.0",
  "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" : "2024-11-23T08:20:40+00:00",
  "publisher" : "EHR WG",
  "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.",
  "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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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/StructureDefinition/requirements-dependent",
          "valueBoolean" : false
        }
      ],
      "key" : "EHRSFMR2.1-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)."
    }
  ]
}