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Req-1013Standard terminology for medications and treatments2013 Format
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use...
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use existing terminologies that represent clinical medications, such as MediSpan, First Data Bank or Multum to support this function. However, EHR systems may also maintain their own proprietary medication terminology. In either case, the scope of the functionality for EHR systems relates to their ability to allow users to encode medications according to a standard representation.
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Medication Management, Special Terminology and InformationNormative Statementsno
Req-1015Standard terminology for laboratory testing2013 Format
The system SHOULD provide the ability to encode laboratory and other testing names common to children using a terminology identified as a standard for documenting laboratory names .
Comment: In some cases, laboratory and other...
The system SHOULD provide the ability to encode laboratory and other testing names common to children using a terminology identified as a standard for documenting laboratory names .
Comment: In some cases, laboratory and other testing is managed by a laboratory information system that is either a component of or external to the EHR system. In those cases, the laboratory information system can use the terminology identified as a standard for documenting laboratory and testing names. In other cases, results from laboratory and other testing is entered directly into the EHR system by a healthcare provider. For example, office-based testing for streptococcus, pregnancy or infectious mononucleosis typically would not be documented in a laboratory information system. A user may prefer not to provide the terminology mapping to a specific vocabulary; however the EHR system may have this already linked in their system.
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Special Terminology and InformationNormative Statementsno
Req-1012Standard terminology for diagnoses2013 FormatThe system SHOULD provide the ability to encode diagnoses using a terminology identified as an adequate standard for documenting diagnoses common in childhood.Special Terminology and InformationNormative Statementsno
Req-1011Standard child health terminology for system communication2013 FormatThe system SHALL provide the ability to use a standard terminology for child health (if available to communicate with other systems (internal or external to the EHR-SSpecial Terminology and InformationNormative Statementsno
Req-296Standard Terminologies and Terminology Services2013 Format
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated...
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated by the consistency of human and machine interpretation of shared data and reports. It includes the capture and support of consistent data for templates and decision support logic.

Terminology standards pertain to concepts, representations, synonyms, relationships and computable (machine-readable definitions. Terminology services provide a common way for managing and retrieving these items.
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Medication Management, Special Terminology and InformationHeaderno
Req-715Standard Terminologies and Terminology Models2013 Format
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a...
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc. Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
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Medication Management, Special Terminology and InformationFunctionno
Req-278Standard Report Generation2013 Format
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making,...
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making, audit trail and metadata reporting, as well as to create reports for patients. Many systems may use internal or external reporting tools to accomplish this (such as Crystal Report
Reports may be based on structured data and/or unstructured text from the patient's health record.
Users need to be able to sort and/or filter reports. For example, the user may wish to view only the diabetic patients on a report listing patients and diagnoses.
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Activity Clearance, Birth Information, EPSDT, Well Child/Preventive CareFunctionno
Req-97Sport/Activity-specific exams2013 Format
The system SHALL allow for sport- or activity-specific examinations as outlined by groups such as the American Heart Association (AHA American Academy of Pediatrics (AAP and American Medical Association (AMA For example, supporting the inclusion...
The system SHALL allow for sport- or activity-specific examinations as outlined by groups such as the American Heart Association (AHA American Academy of Pediatrics (AAP and American Medical Association (AMA For example, supporting the inclusion of an EKG for participants in contact sports such as football. These data SHOULD be stored as distinct data elements.
AAP Preparticipation Physical Evaluation: http://www.aap.org/sections/sportsmedicine/PPEAbout.cfm Exit Disclaimer
AHA Recommendations for Physical Activity and Recreational Sports Participation for Young Patients With Genetic Cardiovascular Diseases: http://circ.ahajournals.org/content/109/22/2807.full#sec-10 Exit Disclaimer
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Activity ClearanceNormative Statementsno
Req-455Sport/Activity Clearances2013 Format
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should...
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should not be confused with a well-child physical examination conducted for the purpose of establishing a patient's health status nor should it be confused with the inpatient examination, assessment, or history and physical. Elements of the Activity Clearance may be specific to the requesting entity (e.g. a school district or the requesting entity may provide a specific form for the clinician to report his or her findings. Alternate names for these types of examinations include: Sports Qualifying Examinations, Clearance forms, and Pre-participation screens.
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Activity Clearance, Well Child/Preventive CareHeaderno
Req-1120Specify standard views of immunization information2013 FormatThe system SHOULD provide the ability to specify standard views of patient immunization information for each vaccine dose administration. These SHOULD be able to include patient-specific data, such as patient age on dates of administration, and SHOULD support templates, such as brief (card view and detailed (all information views.ImmunizationsNormative Statementsno
Req-593Source of allergy 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-637Site-specific care plans and guidelines2013 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-669Sibling data sharing2013 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 DataNormative Statementsno
Req-1127Show available dose options for recommended antigens2013 FormatThe system SHOULD provide the ability to display vaccine dose (brand/product/price options for recommended antigens, including combination vaccines given a patient's immunization history and demographic and clinical data.ImmunizationsNormative Statementsno
Req-677Service reports2013 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.
Registry LinkagesNormative Statementsyes
Req-1246Separate consent, assent and permission2013 FormatThe system SHALL support the recording of consent, assent, and permission as separate artifacts.Security and ConfidentialityNormative Statementsno
Req-1140Send real-time queries on patients to IIS2013 FormatThe system SHALL provide the ability to send standard queries in real-time for immunization data regarding individual patients to Immunization Information Systems (IISsImmunizations, Registry LinkagesNormative Statementsno
Req-1256Send age-specific questionnaires2013 FormatThe system SHALL be capable of sending age-specific questionnaires to a variety of people involved in a child's life, including relationships specified ad hoc.Well Child/Preventive CareNormative Statementsno
Req-116Select growth data reference standards2013 FormatThe system SHALL allow user selection of appropriate reference standards (e.g. CDC, WHO, Down's, or Turner's Syndrome display corresponding growth reference percentile curves/calculations, and denote the growth reference used in calculation and display.Growth DataNormative Statementsyes
Req-1254Segmented access to information2013 FormatThe system SHALL have the ability to segment health care data and provide views of the record that correspond to granular authorizations as to data-type, user, and/or purpose, as provided by the parent/guardian and/or the minor, as relevant.Security and ConfidentialityNormative Statementsno
Req-294Security2013 Format
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce...
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce security, all EHR-S applications must adhere to the rules established to control access and protect the privacy of EHR information. Security measures assist in preventing unauthorized use of data and protect against loss, tampering and destruction. An EHR-S must be capable of including or interfacing with standards-conformant security services to ensure that any Principal (user, organization, device, application, component, or object accessing the system or its data is appropriately authenticated, authorized and audited in conformance with local and/or jurisdictional policies.

An EHR-S should support Chains of Trust in respect of authentication, authorization, and privilege management, either intrinsically or by interfacing with relevant external services.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security...
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security and Confidentiality
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Headerno
Req-702Secure Data Routing2013 Format
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the...
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the entities (applications, institutions, directories it expects. This function depends on entity authorization and authentication to be available in the system. For example, a physician practice management application in an EHR-S might send claim attachment information to an external entity. To accomplish this, the application must use a secure routing method, which ensures that both the sender and receiving sides are authorized to engage in the information exchange. Known sources and destinations can be established in a static setup or they can be dynamically determined. Examples of a static setup are recordings of IP addresses or recordings of DNS names. For dynamic determination of known sources and destinations systems can use authentication mechanisms as described in Req-759 (HL7 ID: IN.1.1 For example, the sending of a lab order from the EHRS to a lab system within the same organization usually uses a simple static setup for routing. In contrast sending a lab order to a reference lab outside of the organization will involve some kind of authentication process.
In general, when the underlying network infrastructure is secure (e.g. secure LAN or VPN the simple static setup is used.
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Parents and Guardians and Family Relationship DataFunctionno
Req-429Screening tool status2013 FormatThe system SHALL capture the administration, completion, and evaluation of screening tools.Well Child/Preventive CareNormative Statementsno
Req-1101School-based care delivery data2013 FormatThe system MAY enable controlled access to and display of school based care delivery data.Patient Portals - PHRNormative Statementsno
Req-1016Scales and Scoring2013 FormatMedical care of children relies on a myriad of specialized scales and scoring systems.Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
Req-1022Sarnat scores2013 FormatThe system SHALL support Sarnat scores for hypoxic ischemic encephalopathy.Specialized Scales/ScoringNormative Statementsno
Req-1038Salter-Harris classification of physeal injuries2013 FormatThe system SHALL support the Salter-Harris classification of physeal injuries.Specialized Scales/ScoringNormative Statementsno
Req-934Rupture of membranes details2013 FormatThe system SHALL record if rupture of membranes was spontaneous (SROM artificial (AROM premature (PROM or preterm, premature (PPROMBirth InformationNormative Statementsno
Req-1236Rounding for administrable doses2013 FormatThe system SHALL enable calculated doses (e.g. weight-based to be rounded to optimize administration convenience.Medication ManagementNormative Statementsyes
Req-1222Rights to authorize care and release information2013 FormatThe system SHALL have the ability to store, retrieve, and display information about rights to authorize care and to release information, as well as relevant consent forms.Child Welfare, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1048Reynell-Zinkin Scales2013 FormatThe system SHALL support the Reynell-Zinkin Developmental Scales.Specialized Scales/ScoringNormative Statementsno
Req-513Retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the victim, teen pregnancy and births.2013 FormatIn cases of child abuse the system SHOULD provide the ability to retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the patient, teen pregnancy and births.Child Abuse Reporting, Well Child/Preventive CareNormative Statementsno
Req-949Respiratory support in neonatal resuscitation2013 FormatThe system SHALL record respiratory support used during resuscitation (Blow-by O2, Nasal Cannula O2, Bag / Mask Ventilation, CPAP, or Endotracheal IntubationBirth InformationNormative Statementsno
Req-894Require documentation of therapeutic labs2013 FormatThe system SHOULD provide the ability to require documentation of therapeutic labs or appropriate lab levels recommended for child dosing.Medication ManagementNormative Statementsno
Req-610Reporting immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsyes
Req-673Report summaries: hard copy and electronic2013 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.
Immunizations, Registry LinkagesNormative Statementsno
Req-809Report results of non-blood spot newborn screening tests2013 FormatThe system SHALL be able to report results of non-blood spot newborn screening tests to the state public health department according to their guidelines.Newborn ScreeningNormative Statementsno
Req-600Report immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsno
Req-579Report demographic 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.
Birth Information, Child WelfareNormative Statementsno
Req-1145Report adverse immunization events per legal requirements2013 FormatIF the system has the capacity to prepare reports of patient adverse events due to immunizations, THEN the system SHALL prepare the report according to the requirements of local, state and federal agencies as specified by law.Immunizations, Registry LinkagesNormative Statementsno
Req-595Report adverse events2013 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.
Immunizations, Registry LinkagesNormative Statementsno
Req-250Report Generation2013 Format
STATEMENT: Support the export of data or access to data necessary for report generation and ad hoc analysis.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for the generation of both standard...
STATEMENT: Support the export of data or access to data necessary for report generation and ad hoc analysis.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for the generation of both standard and ad hoc reports. These reports may be needed for clinical, administrative, and financial decision-making, as well as for patient use. Reports may be based on structured data and/or unstructured text from the patient's health record.
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Activity Clearance, Birth Information, EPSDT, Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, Well Child/Preventive CareHeaderno
Req-1196Registry support for alerts2013 FormatThe system MAY access registry information (e.g. date of immunization, demographics of subject, name of vaccine to issue alerts within the EHR for specific patient cases.Immunizations, Registry LinkagesNormative Statementsno
Req-694Registry and Directory Services2013 Format
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and...
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and employers for administrative and financial purposes;
- public health agencies for healthcare purposes, and
- healthcare resources and devices for resource management purposes.
DESCRIPTION: Registry and directory service functions are critical to successfully managing the security, interoperability, and the consistency of the health record data across an EHR-S. These services enable the linking of relevant information across multiple information sources within, or external to, an EHR-S for use within an application.
Directories and registries support communication between EHR Systems and may be organized hierarchically or in a federated fashion. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider's EHR-S interrogates a local, regional, or national registry to find the patient's previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules.
An example of local registry usage is an EHR-S application sending a query message to the Hospital Information System to retrieve a patient's demographic data.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
Req-277Registry Notification2013 Format
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal...
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal health information to disease specific registries, other notifiable registries such as immunization registries, through standard data transfer protocols or messages. The user can update and configure communication for new registries.
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Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
Req-1287Referral for dental services2013 FormatThe system SHOULD facilitate a dental referral according to the appropriate periodicity schedule (generally by age one or at eruption of the first tooth, and biannually thereafter or whenever indicated by abnormal findings.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1273Referral for Non-Medical Psychosocial Problems2013 FormatThe care of children includes interfaces with the psychosocial world of children. This includes, for example, parents, teachers, governmental bodies, and counselors. Issues include who to contact within non-medical organization, what legal responsibilities and procedural requirements exist, and how to interact with non-medical organization and individuals.Well Child/Preventive CareFunctionno
Req-798Referral completion capture2013 FormatThe system SHOULD provide the ability to capture completion of a referral appointment.Primary Care ManagementNormative Statementsno
Req-1274Reference of non-medical resources for psychosocial problems2013 FormatThe system SHOULD have a reference of non-medical resources for psychosocial problems.Well Child/Preventive CareNormative Statementsno
Req-975Record well-child data elements independently2013 FormatThe system SHOULD record values for an accepted list of well-child data elements in a way that enables them to be retrieved independent of other history.Well Child/Preventive CareNormative Statementsno
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