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Req-914Maternal gonorrhea status2013 FormatThe system SHALL record maternal gonorrhea status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-925Maternal drug screening results2013 FormatThe system SHALL record drug screening results including drug tested and results (Positive, Negative, or UnknownBirth InformationNormative Statementsno
Req-915Maternal chlamydia status2013 FormatThe system SHALL record maternal chlamydia Status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-1156Maternal blood type2013 FormatThe system SHALL capture maternal blood type including Rh factor in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-911Maternal VDRL status2013 FormatThe system SHALL record maternal syphilis status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-912Maternal HIV status2013 FormatThe system SHALL record maternal HIV status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-1154Maternal Group B strep status2013 FormatThe system SHALL capture maternal Group B strep status and prophylaxis according to current guidelines from the CDC into the child's chart.Prenatal ScreeningNormative Statementsno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-665Mask selected EHR 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.
Security and ConfidentialityNormative Statementsyes
Req-1151Manually import maternal data into patient history2013 FormatWhen electronic access to the mother's data is not possible, the system SHOULD enable incorporation of selected maternal prenatal and perinatal data by manual entry into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1178Manage roles and permissions for child abuse data2013 FormatThe system SHOULD provide the ability to define and manage roles and permissions to access specific sections of the system with role-based access including, but not limited to, access to child abuse data by child welfare agents and physicians.Child Abuse ReportingNormative Statementsno
Req-1257Manage results of questionnaires2013 FormatThe system SHALL have the ability to send, score, and support the results of questionnaires in a variety of formats, including web-based, paper, and telephone-based.Well Child/Preventive CareNormative Statementsno
Req-1207Manage progress summaries, assessments, and service plans2013 FormatThe system SHOULD retrieve, capture, store, and display a child's progress summaries, assessments, and service plans.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1058Manage language preferences2013 FormatThe system SHALL capture the child's preferred language, including sign language (separately from that of the parent/caregiver and whether an interpreter is necessary.Children with Special Healthcare NeedsNormative Statementsno
Req-1109Manage immunization inventory2013 FormatManage immunization inventoryImmunizationsFunctionno
Req-1118Manage immunization data for quality measures2013 FormatThe system SHALL provide the ability to manage (search, retrieve, display, sort/filter, calculate immunization data to determine immunization rates (and other quality measures for practices and subsets (by provider, by care group, by patient population, age groups, etc.ImmunizationsNormative Statementsno
Req-1009Manage data associated with breast milk products2013 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-1211Manage child’s health history2013 FormatThe system SHALL provide the ability to access, capture, store, display, and manage a child's health history including medication lists, medication allergies, adverse reactions, and immunizations.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-767Manage Structured Health Record Information2013 Format
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
-...
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHRS (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.
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Well Child/Preventive CareFunctionno
Req-264Manage Results2013 Format
STATEMENT: Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
DESCRIPTION: Results of tests are presented in an easily accessible...
STATEMENT: Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
DESCRIPTION: Results of tests are presented in an easily accessible manner to the appropriate providers. Flow sheets, graphs, or other tools allow care providers to view or uncover trends in test data over time. In addition to making results viewable, it is often necessary to send results to appropriate providers using electronic messaging systems, pagers, or other mechanisms. Documentation of notification is accommodated. Results may also be routed to patients electronically or by letter.
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Primary Care ManagementFunctionno
Req-568Manage Referrals2013 Format
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking...
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking of a referral from one care provider to another is supported, whether the referred to or referring providers are internal or external to the healthcare organization. Guidelines for whether a particular referral for a particular patient is appropriate in a clinical context and with regard to administrative factors such as insurance may be provided to the care provider at the time the referral is created.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-263Manage Problem List2013 Format
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists...
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of historical information and tracking the changing character of problem(s and their priority. The source (e.g. the provider, the system id, or the patient of the updates should be documented. In addition all pertinent dates are stored. All pertinent dates are stored, including date noted or diagnosed, dates of any changes in problem specification or prioritization, and date of resolution. This might include time stamps, where useful and appropriate. The entire problem history for any problem in the list is viewable.
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Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareFunctionno
Req-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
Req-262Manage Patient-Specific Care and Treatment Plans2013 Format
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the...
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
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Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareFunctionno
Req-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
Req-268Manage Patient History2013 Format
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient...
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.
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Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening,...
Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening, Primary Care Management, Security and Confidentiality, Specialized Scales/Scoring, Well Child/Preventive Care
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Functionno
Req-128Manage Patient Demographics2013 Format
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth,...
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, time of birth, gestation, gender, and other information is stored and maintained for unique patient identification, reporting purposes and for the provision of care. Patient demographics are captured and maintained as discrete fields (e.g., patient names and addresses and may be enumerated, numeric or codified. Key patient identifiers are shown on all patient information output (such as name and ID# on each screen of a patient's record The system will track who updates demographic information, and when the demographic information is updated.
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Birth Information, Child Welfare, Genetic information, Growth Data, Patient Identifier, Prenatal Screening, Well Child/Preventive CareFunctionno
Req-122Manage Patient Clinical Measurements2013 Format
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of...
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of care. Other clinical measures (such as expiratory flow rate, size of lesion, etc. are captured and managed, and may be discrete data.
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EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive CareFunctionno
Req-680Manage Orders for Blood Products and Other Biologics2013 Format
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics...
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics including discontinuance orders. Use of such products in the provision of care is captured. Blood bank or other functionality that may come under jurisdictional law or other regulation (e.g. by the FDA in the United States is not required; functional communication with such a system is required.
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Medication ManagementFunctionno
Req-696Manage Order Sets2013 Format
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease...
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease state according to standards or other criteria. Recommended order sets may be presented based on patient data or other contexts.
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Well Child/Preventive CareFunctionno
Req-698Manage Non-Medication Patient Care Orders2013 Format
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and...
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and discontinue orders. Examples include orders to transfer a patient between units, to ambulate a patient, for medical supplies, durable medical equipment, home IV, and diet or therapy orders.
Each item ordered includes the appropriate detail, such as order identification and instructions. Orders should be communicated to the correct service provider for completion.
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Medication ManagementFunctionno
Req-740Manage Medication Orders2013 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 ManagementFunctionno
Req-259Manage Medication List2013 Format
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start,...
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.
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Medication ManagementFunctionno
Req-258Manage Immunization List2013 Format
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured...
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured as discrete data elements including date, type, manufacturer and lot number. The entire immunization history is viewable.
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Activity Clearance, Immunizations, Medication ManagementFunctionno
Req-257Manage Immunization Administration2013 Format
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance...
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient's immunization history.
DESCRIPTION: During an encounter, recommendations based on accepted immunization schedules are presented to the provider. Allergen and adverse reaction histories are checked prior to giving the immunization. If an immunization is administered, discrete data elements associated with the immunization including date, type, manufacturer and lot number are recorded. Any new adverse or allergic reactions are noted. If required, a report is made to the public health immunization registry.
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Activity Clearance, EPSDT, Immunizations, Registry LinkagesFunctionno
Req-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-1008Manage Data Associated with Breast Milk Storage and Administration2013 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 CareFunctionno
Req-256Manage Consents and Authorizations2013 Format
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment...
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
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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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Functionno
Req-255Manage Clinical Documents and Notes2013 Format
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on...
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphical, audio, etc.. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-254Manage Assessments2013 Format
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the...
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the patient, such as growth charts, developmental profiles, and disease specific assessments. Wherever possible, this assessment should follow industry standard protocols although, for example, an assessment for an infant will have different content than one for an elderly patient. When a specific standard assessment does not exist, a unique assessment can be created, using the format and data elements of similar standard assessments whenever possible.
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Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care...
Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care Management, Registry Linkages, Special Terminology and Information, Well Child/Preventive Care
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Functionno
Req-253Manage Allergy, Intolerance and Adverse Reaction List2013 Format
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates,...
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s includes all reactions including those that are classifiable as a true allergy, intolerance, side effect or other adverse reaction to drug, dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are maintained.
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Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive CareFunctionno
Req-276Maintenance and Versioning of Standard Terminologies2013 Format
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes,...
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes, retired codes, redirected codes Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by local policy.
DESCRIPTION: Version control allows for multiple sets or versions of the same terminology to exist and be distinctly recognized over time.
Terminology standards are usually periodically updated, and concurrent use of different versions may be required. Since the meaning of a concept can change over time, it is important that retrospective analysis and research maintains the ability to relate changing conceptual meanings. If the terminology encoding for a concept changes over time, it is also important that retrospective analysis and research can correlate the different encodings to ensure the permanence of the concept. This does not necessarily imply that complete older versions of the terminology be kept in the EHR-S, only access to the changes needs to be maintained.
It should be possible to retire deprecated versions when applicable business cycles are completed while maintaining obsolescent code sets. An example use of this is for possible claims adjustment throughout the claim's lifecycle.
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Special Terminology and InformationFunctionno
Req-1177Maintain unsubstantiated instances of abuse or neglect2013 Format
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability...
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability to expunge or limit communication to certain external systems unsubstantiated instances of abuse or neglect when required by the prevailing law.
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Child Abuse ReportingNormative Statementsno
Req-578Locate records based on previous names2013 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-886Liquid drug prescriptions2013 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-1105Link vaccine doses to specific patients2013 FormatLink vaccine doses to specific patientsImmunizationsFunctionno
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