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Children's EHR Format Requirement Comparison

(No Match) Requirement ID: Req-254: Manage Assessments Req-715: Standard Terminologies and Terminology Models
(Matches) Release Package: 2013 Format 2013 Format
(No Match) Title: Manage Assessments Standard Terminologies and Terminology Models
(No Match) Description: STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the patient, such as growth charts, developmental profiles, and disease specific assessments. Wherever possible, this assessment should follow industry standard protocols although, for example, an assessment for an infant will have different content than one for an elderly patient. When a specific standard assessment does not exist, a unique assessment can be created, using the format and data elements of similar standard assessments whenever possible.
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally).
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc.). Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
(No Match) Topic Area(s): Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care Management, Registry Linkages, Special Terminology and Information, Well Child/Preventive Care Medication Management, Special Terminology and Information
(Matches) Provenance: HL7 EHR FM R1 HL7 EHR FM R1
(Matches) Achievability:
(Matches) Requirement Type: Function Function
(Matches) Shall/Should/May:
(Matches) Critical/Core: no no
(Matches) Status: Released Released
(Matches) Links:
(No Match) See Also: DC.1.5, DC.1.6.2, DC.1.10.1, DC.2.1.1, DC.2.1.2, DC.2.2.1, S.2.2.1, IN.1.6, IN.2.5.1, IN.2.5.2, IN.4.1, IN.4.2, IN.4.3, IN.5.1, IN.5.2, IN.6
(Matches) Comments:
(Matches) Additional Information:
(Matches) Implementation Notes:
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