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Req-2043: Scales and Scoring
Release Package: 2015 Priority List


Release Package:

2015 Priority List

Requirement ID:

Req-2043

Title:

Scales and Scoring

Description:

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.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-2043 is associated with 2013 Format Req-457 Support the capture of coded pediatric functional health status measures Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-488 Incorporate scale and score tools Normative Statements SHOULD Compare
Req-2043 is associated with 2013 Format Req-1018 Support Apgar scores Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1019 Gestational age estimation Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1020 Finnegan Neonatal Abstinence Scoring (NAS) Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1021 N-PASS Neonatal Pain Scale Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1026 Modified Glasgow Coma Scale Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1034 Pediatric Glasgow Coma Scale Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1037 Wong-Baker FACES pain scale Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1039 Tanner stages of adolescent development Normative Statements SHALL Compare
Req-2043 is associated with 2013 Format Req-1050 Denver Developmental Screening Test Normative Statements SHOULD Compare
Req-2043 is associated with 2013 Format Req-1222 Rights to authorize care and release information Normative Statements SHALL Compare

Requirement Type:

Normative Statement

Shall/Should/May:

SHALL

Critical/Core:

Yes

Status:

Released

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 Exit Disclaimer).
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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Last Updated 05/27/2016
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