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|Requirement ID:||Req-253: Manage Allergy, Intolerance and Adverse Reaction List||Req-767: Manage Structured Health Record Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Allergy, Intolerance and Adverse Reaction List||Manage Structured Health Record Information|
|Description:||STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible) and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s) includes all reactions including those that are classifiable as a true allergy, intolerance, side effect or other adverse reaction to drug, dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are maintained.
|STATEMENT: Create, capture, and maintain structured health record information.
DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.
Examples of structured health information include:
- patient address (non-codified, but discrete field)
- diastolic blood pressure (numeric)
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers
Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHRS (e.g., Subjective/Objective/Assessment/Plan) but unstructured in others.
|Topic Area(s):||Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Records Management, Registry Linkages, Well Child/Preventive Care||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||DC.188.8.131.52, S.2.2.1, S.2.2.3, S.3.7.1, IN.2.5.1, IN.2.5.2, IN.4.1, IN.4.2, IN.4.3, IN.6|