ISO/HL7 10781 - Electronic Health Record System Functional Model, Release 2.1
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Requirements: CPS.3.3 Support for Standard Care Plans, Guidelines, Protocols (Function)

Active as of 2024-11-26
Statement N:

Support the use of appropriate standard care plans, guidelines, protocols, and/or clinical pathways for the management of specific conditions.

 Description I:

A core capability of Clinical Decision Support is that of providing guidelines, plans and protocols to clinicians. These templates or forms can be specific for populations, medical conditions or individual patients. Before they can be used in care provision standard care plans, guidelines, protocols, and clinical pathways must be created. These templates or forms may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, protocols and clinical pathways can be identified and reported.

 Criteria N:
CPS.3.3#01 SHOULD

The system SHOULD provide the ability to capture and maintain site-specific care plans, guidelines, protocols, and clinical pathways.
CPS.3.3#02 SHOULD

The system SHOULD provide the ability to maintain site-specific modifications to standard care plans, guidelines, protocols, and clinical pathways obtained from outside sources.
CPS.3.3#03 SHOULD

The system SHOULD determine variances from standard care plans, guidelines, protocols, and clinical pathways and provide the ability to capture, maintain and render appropriate alerts, notifications and reports.
CPS.3.3#04 SHOULD

The system SHOULD determine variances from standard care plans, guidelines and protocols for reportable conditions and provide the ability to capture, maintain and transmit related information to public health.
CPS.3.3#05 SHOULD

The system SHOULD conform to function [[POP.4]] (Support for Monitoring Response Notifications Regarding a Specific Patient's Health).
CPS.3.3#06 SHALL

The system SHALL conform to function [[CPS.3.4]] (Support for Context-Sensitive Care Plans, Guidelines, Protocols).
CPS.3.3#07 SHALL

The system SHALL conform to function [[CPS.3.1]] (Support for Standard Assessments).
CPS.3.3#08 SHOULD

The system SHOULD provide the ability to capture, maintain and render condition-specific guidelines (e.g., based on age or weight).
CPS.3.3#09 SHOULD

The system SHOULD provide the ability to capture documents using standards-based documentation templates to support data exchanges.
CPS.3.3#10 MAY

The system MAY provide the ability to maintain standard choices for disposition (e.g., reviewed and filed, recall patient, or future follow-up).
CPS.3.3#11 SHOULD

The system SHOULD provide the ability to manage patient disposition status configuration parameters.
CPS.3.3#12 SHOULD

The system SHOULD provide the ability to tag and render an indicator that a patient record is incomplete (e.g., not finalized or authenticated/signed).
CPS.3.3#13 SHOULD

The system SHOULD provide the ability to render an indicator that a patient record is incomplete (e.g., not finalized or authenticated/signed) when a discharge or transfer order is entered into the system.
CPS.3.3#14 SHOULD

The system SHOULD tag specific missing elements/sections of incomplete records.
CPS.3.3#15 SHOULD

The system SHOULD capture research protocol deviation information, including any verbatim text of protocol deviation.