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Req-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.Birth InformationNormative Statementsno
Req-942Continuing Apgar scores2013 FormatThe system MAY record Apgar score at every 5 minutes after 10 minutes if the total score is less than; 5 (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-937Record delivery assistance2013 FormatThe system SHALL record if any delivery assistance was required (No Assistance, Forceps, Mid Forceps, High Forceps, or Vacuum ExtractionBirth InformationNormative Statementsno
Req-936Record mechanism of delivery2013 FormatThe system SHALL record the mechanism of delivery (Spontaneous Vaginal Delivery or SVD, Assisted Vaginal Delivery, Precipitous Vaginal Delivery, Emergent Cesarean section, Elective Cesarean sectionBirth InformationNormative Statementsno
Req-9391 minute Apgar2013 FormatThe system SHALL record Apgar score at 1 minute (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-938Initial Infant Data2013 FormatData recorded in the first hour of life will guide care in the initial neonatal period.Birth Information, Specialized Scales/ScoringFunctionno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth InformationNormative Statementsno
Req-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-935Record color of amniotic fluid2013 FormatThe system SHALL record the color of amniotic fluid (clear, cloudy, bloody, light meconium, moderate meconium, thick meconium, terminal meconiumBirth InformationNormative 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-929Record tocolytics administration2013 FormatThe system SHALL record whether mother received tocolytics and, if so, which one(sBirth InformationNormative Statementsno
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-931Additional medications during pregnancy2013 FormatThe system SHALL record any additional prescription and non-prescription medications and supplements (with name, dose, frequency, and route that the mother took during pregnancy.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-926Medication use during pregnancy2013 FormatPrescribed medications taken during pregnancy or near the time of birth are important for the care of a newborn infant.Birth InformationFunctionno
Req-927Betamethasone prior to delivery2013 FormatThe system SHOULD record the date and time of all Betamethasone doses given to the mother prior to delivery.Birth InformationNormative Statementsno
Req-924Illicit drug use during pregnancy2013 FormatThe system SHALL record other illicit drugs used during pregnancy (Positive, Negative, or Unknown IF positive THEN the system SHALL record the name, dose and frequency of use.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-922Narcotics use during pregnancy2013 FormatThe system SHALL record narcotics use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of narcotics used per day.Birth InformationNormative Statementsno
Req-923Amphetamine use during pregnancy2013 FormatThe system SHALL record amphetamine use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of amphetamine used per day.Birth InformationNormative Statementsno
Req-920THC use during pregnancy2013 FormatThe system SHALL record THC use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of THC used per day.Birth InformationNormative Statementsno
Req-921Cocaine use during pregnancy2013 FormatThe system SHALL record cocaine use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of cocaine used per day.Birth InformationNormative Statementsno
Req-918Alcohol use during pregnancy2013 FormatThe system SHALL record alcohol use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of alcohol used per day.Birth InformationNormative Statementsno
Req-919Tobacco use during pregnancy2013 FormatThe system SHALL record tobacco use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of tobacco used per day.Birth InformationNormative Statementsno
Req-916Prenatal care provider information2013 FormatThe system SHALL record the prenatal care provider's name and practice affiliation.Birth InformationNormative Statementsno
Req-917Maternal substance abuse and social history2013 FormatMaternal social history and history of substance abuse can have a dramatic impact on the care of a newborn infant.Birth InformationFunctionno
Req-914Maternal gonorrhea status2013 FormatThe system SHALL record maternal gonorrhea status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-915Maternal chlamydia status2013 FormatThe system SHALL record maternal chlamydia 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-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-911Maternal VDRL status2013 FormatThe system SHALL record maternal syphilis status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-910Maternal hepatitis B status2013 FormatThe system SHALL record maternal hepatitis B status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-909Maternal sickle cell status2013 FormatThe system SHALL record maternal sickle cell status as HbSS, HbSC, HbS-Thal, Negative or Unknown.Birth InformationNormative Statementsno
Req-908Maternal rubella status2013 FormatThe system SHALL record maternal rubella status as Immune, Non-Immune or Unknown.Birth InformationNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-903Symmetry2013 FormatThe system SHALL record symmetry at birth as Symmetrical or Asymmetrical.Birth InformationNormative Statementsno
Req-902Infant size relative to gestational age2013 FormatThe system SHALL provide the ability to capture, record and store the birth weight, length and head circumference of the infant relative to normal values for its captured and/or assigned gestational age (SGA=Small for Gestational Age, AGA=Appropriate for Gestational Age, LGA=Large for Gestational AgeBirth InformationNormative 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-900Record singleton, twin, or multiple gestation2013 FormatThe system SHALL record whether the infant is a singleton, twin, or multiple gestation.Birth InformationNormative Statementsno
Req-899Gestational age based on Dubowitz or Ballard2013 FormatThe system SHALL record gestational age in weeks based on Dubowitz scoring or Ballard Exam.Birth InformationNormative Statementsno
Req-898Gestational age in weeks and days2013 FormatThe system SHALL record gestational age in weeks and days based on last menstrual period (LMP ultrasound, or maternal report.Birth InformationNormative Statementsyes
Req-897Birth weight in kg2013 FormatThe system SHALL record birth weight in kilograms to 3 decimal places.Birth InformationNormative Statementsno
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
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-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-1018Support Apgar scores2013 FormatThe system SHALL support Apgar scores.Specialized Scales/ScoringNormative Statementsno
Req-1019Gestational age estimation2013 FormatThe system SHALL support gestational age estimation based on Ballard Exam or Dubowitz score.Specialized Scales/ScoringNormative Statementsno
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