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|Requirement ID:||Req-767: Manage Structured Health Record Information||Req-1255: External Sources of Developmental and Behavioral Information|
|Release Package:||2013 Format||2013 Format|
|Title:||Manage Structured Health Record Information||External Sources of Developmental and Behavioral Information|
|Description:||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.
|Developmental and Behavioral Information requires information from medical as well as non-medical people who interact with a child including but not limited to parents, teachers, and counselors. Developmental Milestones can be divided many ways all include some aspect of Physical Development, Social /Personal Skills, Cognitive Development, and Communication Skills. In order for a pediatrician to completely assess a child's developmental progress many external pieces of information must be available to the clinician.|
|Topic Area(s):||Well Child/Preventive Care||Well Child/Preventive Care|
|Provenance:||HL7 EHR FM R1||SME|