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 |
Identify and present the appropriate care plans, guidelines, protocols, and/or clinical pathways for the management of patient-specific conditions that are identified in a patient clinical encounter.
At the time of the clinical encounter (problem identification), recommendations for tests, treatments, medications, immunizations, referrals and evaluations are presented based on evaluation of patient-specific data such as age, gender, developmental stage, their health profile, and any site-specific considerations. These may be modified on the basis of new clinical data at subsequent encounters.
CPS.3.4#01 | SHALL |
The system SHALL provide the ability to render care and treatment plans that are sensitive to the context of patient data and assessments. |
CPS.3.4#02 | SHOULD |
The system SHOULD provide the ability to capture and maintain the choice of action in response to care plan suggestions. |
CPS.3.4#03 | SHOULD |
The system SHOULD determine and render alerts, notifications, and reports about variances from standard care plans, guidelines, protocols, and clinical pathways. |
CPS.3.4#04 | SHALL |
The system SHALL conform to function [[CPS.3.1]] (Support for Standard Assessments). |
CPS.3.4#05 | SHALL |
The system SHALL conform to function [[CPS.3.2]] (Support for Patient Context-Driven Assessments). |
CPS.3.4#06 | SHALL |
The system SHALL conform to function [[CPS.3.3]] (Support for Standard Care Plans, Guidelines, Protocols). |
CPS.3.4#07 | SHOULD |
The system SHOULD provide the ability to capture, maintain, and render specialized medical treatment guidelines and protocols for unique physical, chemical, biological, and radiologic exposures. |
CPS.3.4#08 | SHOULD |
The system SHOULD provide the ability to manage biometric data, such as age-specific, weight-specific or height-specific normative data, to identify, track and provide alerts, notifications and reports about variances, care plans, guidelines and protocols. |
CPS.3.4#09 | SHALL |
The system SHALL provide the ability to capture, maintain and render care plan templates to be used as a basis for the creation of new plans of care and treatment. |
CPS.3.4#10 | SHOULD |
The system SHOULD provide the ability to capture care plan templates from previously developed care plans. |