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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-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-1197Auto-populate birth certificate2013 FormatThe system SHOULD be able to auto-populate a birth certificate.Birth InformationNormative 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-676Generate structured clinical and administrative reports2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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, Well Child/Preventive CareNormative Statementsno
Req-1088Prompts to discuss additional health matters2013 FormatThe system MAY prompt the care provider to discuss additional health matters potentially related to the anticipated activity for which clearance is sought.Activity Clearance, Well Child/Preventive CareNormative Statementsno
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-610Reporting immunization history2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-600Report immunization history2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-108Support for Health Maintenance: Preventive Care and Wellness2013 FormatSystem supports Preventive Care and Wellness aspects of health maintenance.Activity Clearance, EPSDT, Newborn Screening, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareHeaderno
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-281Documentation of Care, Measurements and Results2013 FormatSystem will document Care, Measurements and Results
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages,...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive Care
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Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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Req-286Summary Lists2013 FormatSystems ability to capture summary lists.
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family...
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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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-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-284Measurement, Analysis, Research and Reports2013 FormatSystem supports measurement, analysis, research and reports.
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures,...
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Well Child/Preventive Care
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Req-103Care Management2013 Format
Care Management functions are those directly used by providers as they deliver patient care and create an electronic health record. The Record Management (Req-106 functions address the mechanics of creating a...
Care Management functions are those directly used by providers as they deliver patient care and create an electronic health record. The Record Management (Req-106 functions address the mechanics of creating a health record and concepts such as a single logical health record, managing patient demographics, and managing externally generated (including patient originated health data. Thereafter, The additional Care Management functions follow a fairly typical flow of patient care activities and corresponding data, starting with managing the patient history and progressing through consents, assessments, care plans, orders, results etc.

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

In the Direct Care functions there are times when actions/activities related to "patients" are also applicable to the patient representative. Therefore, in this section, the term "patient" could refer to the patient and/or the patient's personal representative (e.g. guardian, surrogate
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Activity Clearance, Birth Information, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Genetic information, Growth Data, Immunizations,...
Activity Clearance, Birth Information, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Genetic information, Growth Data, Immunizations, Medication Management, Newborn Screening, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Special Terminology and Information, Specialized Scales/Scoring, Well Child/Preventive Care
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Req-98Prompts for safety interventions2013 FormatThe system SHOULD prompt the care provider to recommend specific safety interventions such as warm-up exercises and or equipment based on sport or activity.Activity ClearanceNormative Statementsno
Req-99Nutritional status analysis2013 FormatThe system SHOULD allow for nutritional status analysis during activity clearance examinations.Activity ClearanceNormative Statementsno
Req-96Storage of completed clearance forms2013 FormatThe system SHALL provide for the storage of completed clearance forms for individual patients from various agencies, e.g., School District or youth organizations.Activity ClearanceNormative Statementsno
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
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