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|Requirement ID:||Req-249: Health Record Output||Req-253: Manage Allergy, Intolerance and Adverse Reaction List|
|Release Package:||2013 Format||2013 Format|
|Title:||Health Record Output||Manage Allergy, Intolerance and Adverse Reaction List|
|Description:||STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare process, supports selection of specific sections of the health record, and allows healthcare organizations to define the report and/or documents that will comprise the formal health record for disclosure purposes. A mechanism should be provided for both chronological and specified record element output. This may include defined reporting groups (i.e. print sets). For example: Print Set A = Patient Demographics, History & Physical, Consultation Reports, and Discharge Summaries. Print Set B = all information created by one caregiver. Print Set C = all information from a specified encounter. An auditable record of these requests and associated exports may be maintained by the system. This record could be implemented in any way that would allow the who, what, why and when of a request and export to be recoverable for review. The system has the capability of providing a report or accounting of disclosures by patient that meets in accordance with scope of practice, organizational policy and jurisdictional law.
|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.
|Topic Area(s):||Immunizations, Patient Identifier, Records Management, Registry Linkages, Security and Confidentiality, Well Child/Preventive Care||Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Records Management, Registry Linkages, Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||HL7 EHR FM R1|
|See Also:||DC.1.1.4, DC.1.4, IN.1.2, IN.2.5.1, IN.2.5.2, IN.4.1, IN.4.3, IN.5.1, IN.5.4, IN.6||DC.18.104.22.168, 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|