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

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

Page standards status: Informative

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    <Requirements xmlns="http://hl7.org/fhir">
      <id value="EHRSFMR2-CP.8.1"/>
      <meta>
        <profile
                 value="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/FMFunction"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml">
        <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>
    </div></span>

        <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>
    </div></span>

        <span id="actors"><b>Actors:</b><br/> ehr</span>

        <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>

        <table id="statements" class="grid dict">

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#01</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#02</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#03</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#04</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#05</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHALL provide the ability to capture an indication that instructions were given to the patient.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#06</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHALL</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#07</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD provide the ability to annotate patient-specific instructions.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#08</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#09</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>SHOULD</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system SHOULD provide the ability to manage patient instructions in multiple languages.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#10</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on age.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#11</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on gender.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#12</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#13</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <span><div><p>The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level.</p>
    </div></span>

                </td>
            </tr>

            <tr>
                <td style="padding-left: 4px;">

                    <span>CP.8.1#14</span>

                </td>
                <td style="padding-left: 4px;">

                    <span>MAY</span>

                </td>
                <td style="padding-left: 4px;" class="requirement">

                    <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>
    </div></span>

                </td>
            </tr>

        </table>
    </div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="ehr"/>
      </extension>
      <url value="http://hl7.org/ehrs/uv/ehrsfmr2/Requirements/EHRSFMR2-CP.8.1"/>
      <version value="2.1.1-ballot"/>
      <name
            value="CP_8_1_Generate__Record_and_Distribute_Patient_Specific_Instructions"/>
      <title
             value="CP.8.1 Generate, Record and Distribute Patient-Specific Instructions (Function)"/>
      <status value="active"/>
      <date value="2025-04-04T11:04:36+11:00"/>
      <publisher value="HL7 International / Electronic Health Records"/>
      <contact>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/ehr"/>
        </telecom>
      </contact>
      <description
                   value="Generate and record patient-specific instructions related to pre- and post-procedural and post-treatment/discharge requirements."/>
      <jurisdiction>
        <coding>
          <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
          <code value="001"/>
          <display value="World"/>
        </coding>
      </jurisdiction>
      <purpose
               value="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/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-01"/>
        <label value="CP.8.1#01"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL provide the ability to determine and render standardized instruction sets pertinent to the patient condition, for procedures, or scheduled events."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.9#1"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-02"/>
        <label value="CP.8.1#02"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL provide the ability to render instructions pertinent to the patient as selected by the provider."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.9#2"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-03"/>
        <label value="CP.8.1#03"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to transmit instruction information in electronic format to be provided to the patient."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.9#3"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-04"/>
        <label value="CP.8.1#04"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="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 value="EHR-S_FM_R1.1 DC.1.9#4"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-05"/>
        <label value="CP.8.1#05"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHALL provide the ability to capture an indication that instructions were given to the patient."/>
        <derivedFrom value="EHR-S_FM_R1.1 DC.1.9#5"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-06"/>
        <label value="CP.8.1#06"/>
        <conformance value="SHALL"/>
        <conditionality value="false"/>
        <requirement
                     value="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 value="EHR-S_FM_R1.1 DC.1.9#6"/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-07"/>
        <label value="CP.8.1#07"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to annotate patient-specific instructions."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-08"/>
        <label value="CP.8.1#08"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="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."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-09"/>
        <label value="CP.8.1#09"/>
        <conformance value="SHOULD"/>
        <conditionality value="false"/>
        <requirement
                     value="The system SHOULD provide the ability to manage patient instructions in multiple languages."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-10"/>
        <label value="CP.8.1#10"/>
        <conformance value="MAY"/>
        <conditionality value="false"/>
        <requirement
                     value="The system MAY provide the ability to manage a list of appropriate patient instructions based on age."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-11"/>
        <label value="CP.8.1#11"/>
        <conformance value="MAY"/>
        <conditionality value="false"/>
        <requirement
                     value="The system MAY provide the ability to manage a list of appropriate patient instructions based on gender."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-12"/>
        <label value="CP.8.1#12"/>
        <conformance value="MAY"/>
        <conditionality value="false"/>
        <requirement
                     value="The system MAY provide the ability to manage a list of appropriate patient instructions based on diagnosis."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-13"/>
        <label value="CP.8.1#13"/>
        <conformance value="MAY"/>
        <conditionality value="false"/>
        <requirement
                     value="The system MAY provide the ability to manage a list of appropriate patient instructions based on reading level."/>
      </statement>
      <statement>
        <extension
                   url="http://hl7.org/ehrs/uv/ehrsfmr2/StructureDefinition/requirements-dependent">
          <valueBoolean value="false"/>
        </extension>
        <key value="EHRSFMR2-CP.8.1-14"/>
        <label value="CP.8.1#14"/>
        <conformance value="MAY"/>
        <conditionality value="false"/>
        <requirement
                     value="The system MAY provide the ability to render educational materials using alternative modes to accommodate patient sensory capabilities (e.g., vision impairment, hearing impairment)."/>
      </statement>
    </Requirements>