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Children's EHR Format Requirement Comparison

(No Match) Requirement ID: Req-1026: Modified Glasgow Coma Scale Req-2043: Scales and Scoring
(No Match) Release Package: 2013 Format 2015 Priority List
(No Match) Title: Modified Glasgow Coma Scale Scales and Scoring
(No Match) Description: The system SHALL support the Modified Glasgow Coma Scale for infants.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018, 1984.
The system shall allow the capture of data using an established instrument, the creation of reports and displays using the data, and data use in clinical decision support and in the EHR as necessary.
(Matches) Topic Area(s): Specialized Scales/Scoring Specialized Scales/Scoring
(No Match) Provenance: SME Not Applicable
(No Match) Achievability: High
(No Match) Requirement Type: Normative Statements Normative Statement
(Matches) Shall/Should/May: SHALL SHALL
(No Match) Critical/Core: no yes
(Matches) Status: Released Released
(Matches) Links:
(Matches) See Also:
(No Match) Comments: Please see Comment within 'Description'
(Matches) Additional Information:
(No Match) Implementation Notes: Specialized scales and scoring occur in many contexts in a child EHR. Each scale requires a data entry form which may include images to illustrate the choices; a method to import patient- entered data from Web sites, electronic documents, or waiting room apps; a scoring method, a location to store the computed score; or guidelines to assist or provide the interpretation of the results. This information also should be made available in either hard copy or electronically to the patient or parent/guardian as part of the visit note if desired by the physician. The data captured should also be available for extraction through query functionality that allows the user to create reports on a panel of patients. For example, the system should provide the ability to identify all patients that have a particular cutoff score on a depression screening within a specific window of time, so that additional outreach and services are offered, and potential issues are not lost or overlooked.See implementation notes for Req-2004 for information about the sensitivity/specificity threshold established in NQF measure #1448 for screening tools (see https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CB4QFjAA&url=http://www.qualityforum.org/workarea/DownloadAsset.aspx?id%3D52734&ei=fVdsVZPmOoSusAXJtoPQCw&usg=AFQjCNHr0eVXLelOhJfJmAddyqYufxvmTQ&sig2=fRcvw8SSxstN3dV8DqAOPg). At the present time, these is no single standard for distributing the wide variety of scales in a standard electronic format that would automatically generate a data entry form, a Web page, a waiting room app, and facilitate automated import of the data into and EHR with scoring, interpretation, and filing of the results in the EHR. In the absence of standards that would allow a vendor to implement this requirement once with tools that can be reused for any specialized scale and scoring, some of the most important forms for ambulatory use may require custom implementation or a simple workaround with use of a PDF form that can be scanned or imported with results entered manually into discrete data in the EHR. Standards that are under development and implementation for quality measure reporting hold great promise to help move this important feature toward generalized solutions.
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