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|Requirement ID:||Req-848: Record head circumference precisely||Req-2019: Record Gestational Age Assessment and Persist in the EHR|
|Release Package:||2013 Format||2015 Priority List|
|Title:||Record head circumference precisely||Record Gestational Age Assessment and Persist in the EHR|
|Description:||The system SHALL record head circumference at least to the half centimeter, or quarter inch, based on user preference, and record the date of measure.||The system shall capture and display assigned gestational age as well as the diagnosis of SGA=Small for Gestational Age or LGA=Large for Gestational Age when appropriate.|
|Topic Area(s):||Growth Data, Well Child/Preventive Care||Growth Data, Well Child/Preventive Care|
|Requirement Type:||Normative Statements||Normative Statement|
|Implementation Notes:||Gestational age is part of the birth data. The measure is reported as a number of weeks, and is based on the assessment of the infant at birth. The reported value is compared with normative growth parameters to assess the overall growth development of the child. This assessment is classified as small for gestational age (SGA), Appropriate for Gestational Age (AGA), or large for gestational age (LGA), and has lifelong diagnostic, developmental, and predictive implications. (Being born SGA increases the risk for adult hypertension, diabetes, and coronary heart disease.) The assessment should be entered on the problem list and carried forward in time, particularly if it is SGA or LGA. Methods for assessing gestational age include maternal dates, prenatal ultrasound examinations, examination of the newborn, and use of specialized scales and scoring such as the Dubowitz Score. Ideally, the method for assessing gestational age and the source of the data when obtained from external sources should be documented in the EHR. Vital signs may have multiple measurements by multiple providers at multiple points in time. Gestational age also may be measured multiple times—as part of a newborn physical examination, a Dubowitz Score administration, or data imported from the mother’s prenatal or delivery records; however, a single assigned gestational age should be selectable and used for the birth data. In infants born prematurely (before they reach 37 weeks gestational age), it is important that the system calculate and display the Gestation Adjusted Age (also known as “Corrected Age” or “Corrected Gestational Age”) until the child reaches an adjusted age of 24 months old. The Gestation Adjusted Age should be displayed for these infants in all locations where age is displayed. The adjusted gestational age is calculated by this formula: [Gestation Adjusted Age] = [Current Age] - 40 + [Gestational Age at birth]. For example, a 16-week-old child, born at a gestational age of 30 weeks old, has an adjusted age of 16 - (40 - 30) = 6 weeks old. The adjusted gestational age should be displayed in weeks until it reaches 12 weeks old and thereafter in months. The adjusted gestational age is important to interpret developmental milestone and laboratory test results, and is critical to provide appropriate anticipatory guidance.|