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Req-829Present patient age using appropriate units2013 FormatThe system SHALL present patient age using units appropriate to the actual age of the patient, using appropriate thresholds for unit selectionWell Child/Preventive CareNormative Statementsno
Req-261Present Guidelines and Protocols for Planning Care2013 FormatSTATEMENT: Present organizational guidelines for patient care as appropriate to support planning of care, including order entry and clinical documentation.
DESCRIPTION: Guidelines, and protocols presented for planning care may be site specific, community or industry-wide standards.
Primary Care ManagementFunctionno
Req-129Present Alerts for Preventive Services and Wellness2013 Format
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider...
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider or patient is presented with due or overdue activities based on protocols for preventive care and wellness. Examples include but are not limited to, routine immunizations, adult and well child care, age and gender appropriate screening exams, such as PAP smears. The provider may wish to provide reminders to the patient based on the alert.
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EPSDT, Newborn Screening, Well Child/Preventive CareFunctionno
Req-266Present Ad Hoc Views of the Health Record2013 Format
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters,...
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
DESCRIPTION: A key feature of an electronic health record is its ability to support the delivery of care by enabling prior information to be found and meaningfully displayed. EHR systems should facilitate search, filtering, summarization, and presentation of available data needed for patient care. Systems should enable views to be customized, for example, specific data may be organized chronologically, by clinical category, or by consultant, depending on need. Jurisdictional laws and organizational policies that prohibit certain users from accessing certain patient information must be supported.
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Immunizations, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareFunctionno
Req-1159Prenatal ultrasound results2013 FormatThe system SHALL capture into the child's chart any specific condition diagnosed by prenatal ultrasound in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1160Prenatal testing results2013 FormatThe system SHALL capture into the child's chart results of maternal testing for conditions in the newborn (e.g., the "quad screen" or "triple screen" in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1161Prenatal in utero testing results2013 FormatThe system SHALL capture into the child's chart results of any specific condition diagnosed by in utero testing (e.g., amniocentesis in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-916Prenatal care provider information2013 FormatThe system SHALL record the prenatal care provider's name and practice affiliation.Birth InformationNormative Statementsno
Req-1029Pregnancy drug compatibility categories2013 FormatThe system SHALL support pregnancy drug compatibility categories (A, B, C, D, XSpecialized Scales/ScoringNormative Statementsno
Req-1017Pregnancy and infancy scores and scales2013 FormatSeveral scales and scoring systems are used to represent data needed to care for infants in the neonatal / perinatal period.Specialized Scales/ScoringFunctionno
Req-287Preferences, Directives, Consents and Authorizations2013 FormatMaintain preferences, directives, consents and authorizations.
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Headerno
Req-874Predictive growth and clinical context2013 FormatPredictive growth and clinical contextGrowth DataHeaderno
Req-1110Predict practice-level immunization needs2013 FormatThe system MAY provide the ability to estimate/determine the number of types and doses of immunizations that will be required by a practice over a given period of time going forward (1 month, 3 months, etc. based on patient lists and demographics.ImmunizationsNormative Statementsno
Req-838Precise birth date and time storage2013 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 InformationNormative Statementsno
Req-837Precise birth date and time entry2013 FormatThe system SHALL enable entry of the date and time of birth (no less precisely than to the minute if required by the scope of practice.Birth InformationNormative Statementsyes
Req-1071Pre-visit forms2013 FormatThe system SHOULD allow pre-visit forms to be completed by parents/caregivers or children or a combination of both.Well Child/Preventive CareNormative Statementsno
Req-1221Placement setting in out-of-home care2013 FormatThe system SHALL have the ability to store, retrieve and display the current placement setting of the child in out-of-home care.Child WelfareNormative Statementsno
Req-978Physical exam screening results2013 FormatThe system SHALL allow documentation of the presence or absence of age- and gender-specific physical exam findings.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1164Pertinent family history for screening2013 FormatThe system SHOULD incorporate documentation of pertinent family history to screen children at risk for common chronic conditions such as asthma and diabetes.Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1094Personal Health Record Access2013 Format
A personal health record (PHR for children is a significantly complex issue, but one that must have a perfunctory overview in the child EHR specifications. The PHR allows a person, in this case child or...
A personal health record (PHR for children is a significantly complex issue, but one that must have a perfunctory overview in the child EHR specifications. The PHR allows a person, in this case child or parent, to view their clinical history as aggregated from many sources and must be compliant with the appropriate statutes (federal, state and local In addition to the viewing of their history, users of a PHR can enter their own data as they deem pertinent. These data can range from social history to over the counter medications.

The PHR should be accessible by the child, parents, guardians, caregivers and other consumers to enable assessment of compliance with school or leisure activity requirements. This multiple person access requirements must be managed within legal and appropriate security constraints.
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Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityFunctionno
Req-928Perinatal magnesium sulfate administration2013 FormatThe system SHALL record whether the mother received magnesium sulfate doses prior to or during delivery.Birth InformationNormative Statementsno
Req-930Perinatal antibiotic administration2013 FormatThe system SHALL record the type, date, time, and number of antibiotic doses administered before and during delivery.Birth InformationNormative Statementsno
Req-566Performance and Accountability Measures2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. These reports may include measures related to process, outcomes, costs of care, may be used in 'pay for performance' monitoring and adherence to best practice guidelines. The system needs to provide the report generating capability to easily create these reports or provide for the export of data to external report generating software.
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Quality MeasuresFunctionno
Req-1210Pediatric conditions and supporting technology2013 FormatThe system SHALL provide the ability to access, capture, store, and display a child's active or chronic conditions and illnesses, mental illness, and technology support needs (ventilator, monitor, surgical site care, wound vac, etc.Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1030Pediatric Scales and Scoring Systems2013 FormatScales and Scoring systems used in the care of children.Specialized Scales/ScoringFunctionno
Req-1034Pediatric Glasgow Coma Scale2013 Format
The system SHALL support the Pediatric Glasgow Coma Scale.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James...
The system SHALL support the Pediatric Glasgow Coma Scale.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018, 1984.
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Specialized Scales/ScoringNormative Statementsno
Req-1259Patient-specific directory for questionnaire delivery2013 FormatThe system SHALL be able to use a patient-specific directory to automatically deliver questionnaires.
Well Child/Preventive CareNormative Statementsno
Req-633Patient-milk product matching2013 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-123Patient, Family and Care Giver Education2013 Format
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in...
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in the language or dialect understood by the patient or representative. Material should be at the level of the patient or representative's level of understanding and sensory capability. Special needs are documented. Material may be disseminated via a mode available to and acceptable by the patient e.g., printed, electronically or otherwise. The review of material between the clinician and the patient, and the patient's understanding of the review, is documented when desired by the clinician. The patient or patient's representatives are able to obtain educational information independently without formal review with the clinician if desired.
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Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-1093Patient reminders to appropriate preventive care recipient2013 FormatThe system SHOULD deliver patient reminders to an appropriate recipient for preventive care, where the recipient selection varies by age and personal circumstances.Well Child/Preventive CareNormative Statementsno
Req-674Patient indicators on 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.
Patient IdentifierNormative Statementsno
Req-1173Patient education at transition to adult care2013 FormatThe system SHOULD support patient education that occurs at the transition of care from pediatric to adult care.Primary Care ManagementNormative Statementsno
Req-1097Patient and Caregiver Views2013 FormatThe child's clinical information should be accessible by the child, parents, guardians, caregivers and other consumers to enable assessment of compliance with school or leisure activity requirements. In addition, it should be usable by caregivers to assure care appropriateness and quality.Immunizations, Patient Portals - PHRFunctionno
Req-832Patient age in units appropriate to environment of care2013 FormatThe system SHALL present patient age using units appropriate to the environment of care as well as the patient age.Well Child/Preventive CareNormative Statementsyes
Req-721Patient Reminder Information Updates2013 Format
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health...
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health organizations, etc. may periodically send updates to patient care providers. The system should be capable of generating patient reminders based on the recommendations of these organizations. Patient reminders could be provided to patients by a number of means including phone calls, or mail. A record of such reminders may become part of a patient's record. Examples of reminders could include a recommended immunization, prophylactic guidelines for MVP, patient self-testing for disease, etc.
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Well Child/Preventive CareFunctionno
Req-274Patient Privacy and Confidentiality2013 Format
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of...
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of EHRs are violated if access to EHRs occurs without authorization. Violations or potential violations can impose tangible economic or social losses on affected patients, as well as less tangible feelings of vulnerability and pain. Fear of potential violations discourages patients from revealing sensitive personal information that may be relevant to diagnostic and treatment services. Rules for the protection of privacy and confidentiality may vary depending upon the vulnerability of patients and the sensitivity of records. Strongest protections should apply to the records of minors and the records of patients with stigmatized conditions. Authorization to access the most sensitive parts of an EHR is most definitive if made by the explicit and specific consent of the patient. Please see the definition of masking in the glossary.
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Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
Req-561Patient Knowledge Access2013 Format
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable...
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable information to research a health question, follow up from a clinical visit, identify treatment options, or other health information needs. The information may be linked directly from entries in the health record, or may be accessed through other means such as key word search. The information may be provided as part of the EHR system but may also include patient information from external databases or specific websites.
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Well Child/Preventive CareFunctionno
Req-574Patient Access Management2013 Format
STATEMENT: Enable a healthcare delivery organization to allow and manage a patient's access to the patient's personal health information.
DESCRIPTION: A healthcare delivery organization will be able to manage a patient's ability to view his...
STATEMENT: Enable a healthcare delivery organization to allow and manage a patient's access to the patient's personal health information.
DESCRIPTION: A healthcare delivery organization will be able to manage a patient's ability to view his or her EHR based on scope of practice, organization policy or jurisdictional law. Typically, a patient has the right to view his or her EHR and the right to place restrictions on who can view parts or the whole of that EHR. For example, in some jurisdictions, minors have the right to restrict access to their data by parents/guardians.
One example of managing a patient's access to his or her data is by extending user access controls to patients.
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Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityFunctionno
Req-1175Past history of abuse and neglect for the child2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect for the child.Child Abuse ReportingNormative Statementsno
Req-1176Past history of abuse and neglect by perpetrator2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect by the alleged perpetrator.Child Abuse ReportingNormative Statementsno
Req-1035PRISM III Pediatric Risk of Mortality Score2013 FormatThe system SHALL support the PRISM III Pediatric Risk of Mortality Score.Specialized Scales/ScoringNormative Statementsno
Req-1041PEDS screen2013 FormatThe system SHALL support the PEDS screen.Specialized Scales/ScoringNormative Statementsno
Req-944Oxygen saturation in delivery room2013 FormatThe system SHALL record percutaneous oxygen saturation measurements in the delivery room.Birth InformationNormative Statementsno
Req-571Outcome Measures and Analysis2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. The system needs to provide the report generating capability to easily create these reports or provide for the export of data to external report generating software. The system may also provide the functionality to prompt for the collection of necessary information at the appropriate time in a patient encounter if such collection need can be properly defined in a supportive workflow.
e.g. Requesting specific information for reporting of emergency services such as gun shot, suspected abuse, communicable diseases etc., or for the collection of additional research data for specific a specific diagnosis.
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Well Child/Preventive CareFunctionno
Req-1223Out-of-home care history2013 FormatThe system SHALL have the ability to store, retrieve, and display whether the child has ever been in out-of-home care (yes or no is sufficientChild WelfareNormative Statementsno
Req-1272Organization of imported psychosocial and case management information2013 FormatThe system SHOULD support the detailed organization of psychosocial and case management information that originates external to the EHR.Well Child/Preventive CareNormative Statementsno
Req-565Orders, Referrals, Results and Care Management2013 FormatSystem supports Orders, Referrals, Results and Care Management.Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareHeaderno
Req-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-607Order blood products in pediatric units2013 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-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
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