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Req-2017: Record diagnoses on patient problem summary list
Release Package: 2015 Priority List


Release Package:

2015 Priority List

Requirement ID:

Req-2017

Title:

Record diagnoses on patient problem summary list

Description:

The system shall be able to record all diagnoses resulting from newborn screening other than 'Normal' and all outstanding newborn screening tasks that have not been performed on a patient problem summary list.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-2017 is associated with 2013 Format Req-815 Record diagnoses on patient problem summary list Normative Statements SHOULD Compare

Topic Area(s):

Requirement Type:

Normative Statement

Shall/Should/May:

SHALL

Critical/Core:

Yes

Status:

Released

Implementation Notes:

Newborn screening is a process and not a single test. It is performed on all newborns in the United States in accordance with Recommended Uniform Screening Panel (RUSP issued by the Secretary of Health and Human Services (HHS under specific State mandates that may add or subtract from the RUSP. Newborn screening is performed in the State of birth and the process will be completed with the appropriate public health agency in the birth State regardless of where the infant lives or receives medical care.
Because if may be difficult to obtain detailed newborn screening results in a form other than paper, and because newborn screening identifies conditions and diagnoses of great importance as well as tasks that need to be performed, it is necessary for an EHR that is used to care for children to record all diagnoses that result from newborn screening AND all incomplete tasks or tests not performed previously on the patient problem summary so that it is brought to the attention of all providers who care for the infant. Failure to complete newborn screening or having possible or probable diagnoses that have not been confirmed may require an alternative method of alerting all providers at all visits when to problem list is unable to include these items as problems with a special status. They are indeed clinical problems that should be brought to the attention of all providers until they are resolved and can be removed from the problem list.
EHRs must have the functionality to query for and display a cohort of patients based on missing and abnormal newborn screening results. The results of these queries must be exportable to other aplllications that may require these data.
Some results of newborn screening are known to the health department and some results (including followup testing which is done in a clinical laboratory and not by repeating the dried blood spot are not known to the health department and it is the responsibility of the primary care physician to keep the newborn screening program informed of additional data that are available. The newborn screening program may not be aware of infants that have not been screened, particularly those born outside of a hospital, and the problem list is a good method for reminding all providers when newborn screening has not been performed.
Most newborn screening is performed in the birth hospital, but all of the results are not always available at the time of newborn discharge. Some States require a second specimen at 1–2 weeks of age and followup testing of infants who received transfusions or had extended NICU stays. Newborn screening that was done in the hospital will be part of a newborn discharge summary, but results that are not available at discharge need to be identified in the ambulatory EHR so that they will be reviewed when available or repeated if necessary. Vendors can address this requirement through an input dialog that is invoked when newborn discharge summary birth data or newborn screening results or specialist consults are received in paper, PDF document, or electronic message form. The practice will be prompted to examine the documents and extract and enter on the problem list any tests not performed (such as no newborn hearing screening any conditions that have been diagnosed, and any followup testing required (including repeat second specimen blood spots to be performed at 1–2 weeks of age in States that require them The problem list, rather than the scanned documents or PDFs, becomes the communication tool for alerting all providers about incomplete tasks or important conditions that have been identified.

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Last Updated 04/13/2016
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