HL7 Electronic Health Record System Functional Model, Release 2.1.1
2.1.1-ballot - Normative Ballot

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

Page standards status: Informative

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).

Actors:
ehr 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).