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Req-1060Clinical decision support for code status2013 FormatThe system SHOULD support the ability to prompt for the provider (appropriate to local processes and workflow to discuss code status with the parent/guardian of a medically complex child with special health care needs upon an initial health & physical evaluation.Children with Special Healthcare NeedsNormative Statementsno
Req-644Clinical data for research study participants2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Primary Care ManagementNormative Statementsno
Req-576Clinical Workflow Tasking2013 Format
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment....
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment. Functions must exist in the EHR-S that support electronically any workflow that previously depended on the existence of a physical artifact (such as the paper chart, a phone message slip in a paper based system. Tasks differ from other more generic communication among participants in the care process because they are a call to action and target completion of a specific workflow in the context of a patient's health record (including a specific component of the record Tasks also require disposition (final resolution The initiator may optionally require a response. For example, in a paper based system, physically placing charts in piles for review creates a physical queue of tasks related to those charts. This queue of tasks (for example, a set of patient phone calls to be returned must be supported electronically so that the list (of patients to be called is visible to the appropriate user or role for disposition. Tasks are time-limited (or finite The state transition (e.g. created, performed and resolved may be managed by the user explicitly or automatically based on rules. For example, if a user has a task to signoff on a test result, that task should automatically be marked complete by the EHR when the test result linked to the task is signed in the system. Patients will become more involved in the care process by receiving tasks related to their care. Examples of patient related tasks include acknowledgement of receipt of a test result forwarded from the provider, or a request to schedule an appointment for a pap smear (based on age and frequency criteria generated automatically by the EHR-S on behalf of the provider.
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Well Child/Preventive CareHeaderno
Req-563Clinical Task Assignment and Routing2013 Format
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom...
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom the task can be assigned will be determined by the specific needs of practitioners in a care setting. Task-assignment lists help users prioritize and complete assigned tasks. For example, after receiving communication (e.g. a phone call or e-mail from a patient, the triage nurse routes or assigns a task to return the patient's call to the physician who is on call. Task creation and assignment may be automated, where appropriate. An example of a system-triggered task is when lab results are received electronically; a task to review the result is automatically generated and assigned to a clinician. Task assignment ensures that all tasks are disposed of by the appropriate person or role and allows efficient interaction of entities in the care process.
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Well Child/Preventive CareFunctionno
Req-297Clinical Support2013 FormatSystem provides Clinical Support.
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well...
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-1170Chronic disease and age-specific educational materials2013 FormatThe system SHOULD incorporate chronic disease and age-specific educational materials, for example diabetes and asthma.Primary Care ManagementNormative Statementsno
Req-642Choice of action based on care plan2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-115Childhood obesity statistics2013 FormatSystem MAY store and display waist circumference and hip circumference and calculate/display waist to hip ratio in patients identified with obesity or cardiovascular risk.Growth DataNormative Statementsno
Req-1237Child-specific therapeutic substances2013 FormatThe system SHOULD enable the ordering of child-specific therapeutic substances, and support units appropriate to children.Medication ManagementNormative Statementsno
Req-892Child-appropriate doses in provider-specific medication lists2013 FormatThe system SHALL support child-appropriate dosing in provider specific medication lists ("favorites" including default route, dose, frequency, and quantity (e.g. accommodate weight-based doses such as <mg or mcg or gm>/kg/dose or <mg or mcg or gm>/kg/dayMedication ManagementNormative Statementsno
Req-1042Child Autism Rating Scale (CARS)2013 FormatThe system SHALL support the Child Autism Rating Scale (CARSSpecialized Scales/ScoringNormative Statementsno
Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
Req-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-1066Caregiver contact information for children with special healthcare needs2013 FormatThe system SHALL provide the ability to capture the names and contact information for primary provider, case managers, and subspecialists that follow a child with special healthcare needs, including their contact information.Children with Special Healthcare Needs, Well Child/Preventive CareNormative Statementsno
Req-1081Care planned items in tracked tasks2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Well Child/Preventive CareNormative Statementsno
Req-1080Care plan items in assigned tasks2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Well Child/Preventive CareNormative Statementsno
Req-291Care and Treatment Plans, Guidelines and Protocols2013 FormatSystem maintains Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-103Care Management2013 Format
Care Management functions are those directly used by providers as they deliver patient care and create an electronic health record. The Record Management (Req-106 functions address the mechanics of creating a...
Care Management functions are those directly used by providers as they deliver patient care and create an electronic health record. The Record Management (Req-106 functions address the mechanics of creating a health record and concepts such as a single logical health record, managing patient demographics, and managing externally generated (including patient originated health data. Thereafter, The additional Care Management functions follow a fairly typical flow of patient care activities and corresponding data, starting with managing the patient history and progressing through consents, assessments, care plans, orders, results etc.

Integral to these care management activities is an underlying system foundation that maintains the privacy, security, and integrity of the captured health information - the information infrastructure of the EHR-S. Throughout the DC functions, conformance criteria formalize the relationships to Information Infrastructure functions. Criteria that apply to all Care Management functions are listed in this header (see Conformance Clause page six for discussion of "inherited" conformance criteria

In the Direct Care functions there are times when actions/activities related to "patients" are also applicable to the patient representative. Therefore, in this section, the term "patient" could refer to the patient and/or the patient's personal representative (e.g. guardian, surrogate
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Activity Clearance, Birth Information, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Genetic information, Growth Data, Immunizations,...
Activity Clearance, Birth Information, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Genetic information, Growth Data, Immunizations, Medication Management, Newborn Screening, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Special Terminology and Information, Specialized Scales/Scoring, Well Child/Preventive Care
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Headerno
Req-1113Capture vaccine administration data from multiple input tools2013 FormatThe system SHOULD provide the ability to capture vaccine administration data from multiple input tools such as keyboard, bar-coding and radio-frequency identification devices.ImmunizationsNormative Statementsno
Req-110Capture patient vital signs2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Growth DataNormative Statementsyes
Req-1074Capture patient relationships2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsyes
Req-1235Capture medication dosing details2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Medication ManagementNormative Statementsno
Req-597Capture medication dates2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Medication ManagementNormative Statementsno
Req-1157Capture maternal problem list2013 FormatThe system SHALL enable selective capture into the child's chart of the maternal problem list by the child's healthcare provider.Prenatal ScreeningNormative Statementsno
Req-1162Capture data that precedes the newborn’s record2013 FormatThe system SHALL allow capture of data that were collected for a newborn before the newborn's electronic record was created.Prenatal ScreeningNormative Statementsyes
Req-640Capture continuum of care processes2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1186Capture child abuse details2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history...
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history specific sexual acts; and mechanism of injury in separate sections (e.g. one section for alleged perpetrator and one section for child
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Child Abuse ReportingNormative Statementsno
Req-506Capture both presence and absence of conditions in history2013 FormatThe system SHALL provide the ability to capture patient history as both a presence and absence of conditions, i.e., the specification of the absence of a personal or family history of a specific diagnosis, procedure or health risk behavior.Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementsno
Req-901Capture and record Birth Order for Multiple Births2013 FormatIf an infant is not a singleton, the system SHALL record the birth order.Birth Information, Patient IdentifierNormative Statementsno
Req-1108Capture and document overrides of immunization notifications2013 Format
IF a provider overrides an immunization notification THEN the system MAY prompt the prescriber for documentation and attestation supporting the override, comprised of: a vaccine dose identifiers, b the patient for whom the dose was...
IF a provider overrides an immunization notification THEN the system MAY prompt the prescriber for documentation and attestation supporting the override, comprised of: a vaccine dose identifiers, b the patient for whom the dose was originally intended, c the patient who received the dose, d the current prescriber (if different from the original provider ordering the dose e the reason for the override and f signature.
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ImmunizationsNormative Statementsno
Req-481Capture and communicate referrals2013 FormatThe system SHALL provide the ability to capture and communicate referral(s to other care provider (s or agencies, whether internal or external to the organization.Primary Care ManagementNormative Statementsno
Req-560Capture Patient-Originated Data2013 Format
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish...
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish patient-originated data that is either provided or entered by a patient from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-originated data intended for use by providers will be available for their use.
Data about the patient may be appropriately provided by:
1. the patient
2. a surrogate (parent, spouse, guardian or
3. an informant (teacher, lawyer, case worker
An electronic health record may provide the ability for direct data entry by any of these.
Patient-originated data may also be captured by devices and transmitted for inclusion into the electronic health record.
Data entered by any of these must be stored with source information. A provider must authenticate patient-originated data included in the patient's legal health record.
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Patient Portals - PHRFunctionno
Req-248Capture Patient Health Data Derived from Administrative and Financial Data and Documentation2013 Format
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data...
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data derived from administrative or financial data from clinically authenticated data. Sources of administrative and financial data relating to a patient's health may provide this data for entry into the health record or be given a mechanism for entering this data directly. The data must be explicitly labeled as derived from administrative or financial data, and information about the source must be linked with that data. Patient health data that is derived from administrative or financial data may be provided by:
1. the patient
2. a provider
3. a payer, or
4. entities that transmit or process administrative or financial data.
Since this data is non-clinical, it may not be authenticated for inclusion in the patient's legal health record. Registration data, which may contain demographic data and pertinent positive and negative histories, is an example of administrative and financial data that may be captured.
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Parents and Guardians and Family Relationship DataFunctionno
Req-125Capture Data and Documentation from External Clinical Sources2013 FormatIncorporate clinical data and documentation from external sources. Mechanisms for incorporating external clinical data and documentation (including identification of source such as image documents and other clinically relevant data are available. Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate.Birth InformationFunctionno
Req-826Calculate patient age to the minute2013 FormatThe system SHOULD calculate patient age no less precisely than the nearest minute for at least the first week of lifeWell Child/Preventive CareNormative Statementsno
Req-825Calculate patient age precisely enough to support environment-specific activities2013 FormatThe system SHALL calculate patient age precisely enough to support environment-specific activities that vary significantly in the first hours, days, and months of life.Well Child/Preventive CareNormative Statementsno
Req-117Calculate growth velocity2013 FormatThe system SHOULD calculate growth velocity between two points on the growth chart selected by the user.Growth DataNormative Statementsno
Req-864Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal place at every well-child visit beginning at 24 months of life.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-865Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal point at any age based on system query.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
Req-964CHIPRA-required quality measures2013 Format
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood...
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood immunization status in a clinic over 1 year beginning in January 2011, or weight assessment for children/adolescents over 2 months beginning in March 2011.
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Quality MeasuresNormative Statementsno
Req-1033Broselow Tape color codes2013 FormatThe system SHALL be able to both record Broselow Tape color codes and translate them into corresponding size / dose categories.Specialized Scales/ScoringNormative Statementsno
Req-634Breast milk aliquot data2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Well Child/Preventive CareNormative Statementsno
Req-1028Breast feeding / breast milk drug compatibility categories2013 FormatThe system SHALL support breast feeding / breast milk drug compatibility categories (1= Compatible, 2=Use With Caution, 3=Unknown with Concerns, X=Contraindicated, ?=Safety not EstablishedSpecialized Scales/ScoringNormative Statementsno
Req-626Bone age2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Growth DataNormative Statementsno
Req-863Body Mass Index2013 FormatBody mass index (BMI is a calculated, based on weight and height. Currently, normative data exist only for children 2 and older. It is usually measured at all well-child visits, but can be assessed at other times based on clinician concern.Children with Special Healthcare Needs, Growth Data, Well Child/Preventive CareFunctionno
Req-1289Blood-lead testing2013 FormatThe system SHOULD alert when blood-lead testing is needed.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
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