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Req-688Encounter/Episode of Care Management2013 Format
STATEMENT: Support the definition of Manage and document the health care needed and delivered during an encounter/episode of care.
DESCRIPTION: Using data standards and technologies that support interoperability, encounter management promotes patient-centered/oriented care and enables...
STATEMENT: Support the definition of Manage and document the health care needed and delivered during an encounter/episode of care.
DESCRIPTION: Using data standards and technologies that support interoperability, encounter management promotes patient-centered/oriented care and enables real time, immediate point of service, point of care by facilitating efficient work flow and operations performance to ensure the integrity of: (1 the health record, (2 public health, financial and administrative reporting, and (3 the healthcare delivery process
This support is necessary for direct care functionality that relies on providing user interaction and workflows, which are configured according to clinical protocols and business rules based on encounter specific values such as care setting, encounter type (inpatient, outpatient, home health, etc. provider type, patient's EHR, health status, demographics, and the initial purpose of the encounter.
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Specialized Scales/ScoringHeaderno
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
Req-1020Finnegan Neonatal Abstinence Scoring (NAS)2013 FormatThe system SHALL support modified Finnegan Neonatal Abstinence Scoring (NASSpecialized Scales/ScoringNormative Statementsno
Req-1021N-PASS Neonatal Pain Scale2013 FormatThe system SHALL support the N-PASS Neonatal Pain Scale.Specialized Scales/ScoringNormative Statementsno
Req-1022Sarnat scores2013 FormatThe system SHALL support Sarnat scores for hypoxic ischemic encephalopathy.Specialized Scales/ScoringNormative Statementsno
Req-1023Intra-ventricular hemorrhage scoring2013 FormatThe system SHALL support intra-ventricular hemorrhage scoring.Specialized Scales/ScoringNormative Statementsno
Req-1032Asthma Severity Scoring2013 FormatThe system SHALL support Asthma Severity Scoring.Specialized Scales/ScoringNormative Statementsno
Req-1033Broselow Tape color codes2013 FormatThe system SHALL be able to both record Broselow Tape color codes and translate them into corresponding size / dose categories.Specialized Scales/ScoringNormative Statementsno
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-1035PRISM III Pediatric Risk of Mortality Score2013 FormatThe system SHALL support the PRISM III Pediatric Risk of Mortality Score.Specialized Scales/ScoringNormative Statementsno
Req-1036Gell-Coombs Classification of Hypersensitivity Disorders2013 FormatThe system SHALL support the Gell-Coombs Classification of Hypersensitivity Disorders.Specialized Scales/ScoringNormative Statementsno
Req-1037Wong-Baker FACES pain scale2013 FormatThe system SHALL support the Wong-Baker FACES pain scale.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-1039Tanner stages of adolescent development2013 FormatThe system SHALL support the Tanner stages of adolescent development.Specialized Scales/ScoringNormative Statementsno
Req-1024Modified Bell Staging Criteria2013 FormatThe system SHALL support the Modified Bell Staging Criteria for necrotizing enterocolitis.Specialized Scales/ScoringNormative Statementsno
Req-1025International classification of retinopathy of prematurity (ICROP)2013 FormatThe system SHALL support the international classification of retinopathy of prematurity (ICROPSpecialized Scales/ScoringNormative Statementsno
Req-1026Modified Glasgow Coma Scale2013 Format
The system SHALL support the Modified Glasgow Coma Scale for infants.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins,...
The system SHALL support the Modified Glasgow Coma Scale for infants.
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-1027INFINIB developmental score2013 FormatThe system SHALL support the infant neurological international battery (INFINIB developmental score.Specialized Scales/ScoringNormative Statementsno
Req-1028Breast feeding / breast milk drug compatibility categories2013 FormatThe system SHALL support breast feeding / breast milk drug compatibility categories (1= Compatible, 2=Use With Caution, 3=Unknown with Concerns, X=Contraindicated, ?=Safety not EstablishedSpecialized Scales/ScoringNormative Statementsno
Req-1029Pregnancy drug compatibility categories2013 FormatThe system SHALL support pregnancy drug compatibility categories (A, B, C, D, XSpecialized Scales/ScoringNormative Statementsno
Req-1030Pediatric Scales and Scoring Systems2013 FormatScales and Scoring systems used in the care of children.Specialized Scales/ScoringFunctionno
Req-1031International Classification for (VUR)2013 FormatThe system SHALL support the International Classification for Vesico-ureteral Reflux (VUR - Grades 1-5.Specialized Scales/ScoringNormative Statementsno
Req-1049Maxfield-Buchholz Social Maturity Scale2013 FormatThe system SHALL support the Maxfield-Buchholz Social Maturity Scale for Blind Pre-school children.Specialized Scales/ScoringNormative Statementsno
Req-1048Reynell-Zinkin Scales2013 FormatThe system SHALL support the Reynell-Zinkin Developmental Scales.Specialized Scales/ScoringNormative Statementsno
Req-1051Draw-a-Person test2013 FormatThe system SHOULD support The Draw-a-Person test (DAP-Goodenough-Harris Drawing TestSpecialized Scales/ScoringNormative Statementsno
Req-1050Denver Developmental Screening Test2013 FormatThe system SHOULD support The Denver Developmental Screening Test.Specialized Scales/ScoringNormative Statementsno
Req-1041PEDS screen2013 FormatThe system SHALL support the PEDS screen.Specialized Scales/ScoringNormative Statementsno
Req-1040Developmental Scores / Intelligence Tests2013 FormatDevelopmental scores and scales are critical to assessing developmental milestones.Specialized Scales/ScoringFunctionno
Req-1043Bayley Scales of Infant Development2013 FormatThe system SHALL support the Bayley Scales of Infant Development.Specialized Scales/ScoringNormative Statementsno
Req-1042Child Autism Rating Scale (CARS)2013 FormatThe system SHALL support the Child Autism Rating Scale (CARSSpecialized Scales/ScoringNormative Statementsno
Req-1045Stanford-Binet Intelligence Scale2013 FormatThe system SHALL support the Stanford-Binet Intelligence Scale.
REF: Binet, Alfred; Simon, Th. (1916 The development of intelligence in children: The Binet-Simon Scale. Publications of the Training School at Vineland New Jersey Department of Research No. 11. E. S. Kite (Trans. Baltimore: Williams & Wilkins. Retrieved 18 July 2010.
Specialized Scales/ScoringNormative Statementsno
Req-1044Conners Comprehensive Behavior Rating Scales2013 FormatThe system SHALL support the Conners Comprehensive Behavior Rating Scales (Conners CBRS™Specialized Scales/ScoringNormative Statementsno
Req-1047Gesell Developmental schedules2013 FormatThe system SHALL support the Gesell Developmental schedules.Specialized Scales/ScoringNormative Statementsno
Req-1046Leiter International Performance scale2013 FormatThe system SHALL support the Leiter International Performance Scale.Specialized Scales/ScoringNormative Statementsno
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-542Multiple terminology versioning2013 FormatThe system SHALL provide the ability to use different versions of terminology standards, (e.g. a child-specific version, when it existsSpecial Terminology and InformationNormative Statementsno
Req-667Preserve concept interpretations across terminology versions2013 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.
Special Terminology and InformationNormative Statementsno
Req-1010Validate clinical terms against a standard terminology2013 FormatThe system MAY provide the ability to validate that clinical terms and coded clinical data exists in an accepted standard terminology for child health (if availableSpecial 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-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-1014Standard terminology for signs, systems, and development2013 FormatThe system SHOULD provide the ability to encode pediatric signs, symptoms and development using a terminology identified as a standard for documenting signs and symptoms.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-550Support patient consent requirements based on law2013 FormatThe system SHOULD determine the need for minor patient consent based on determination of age of majority based on jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-549Define context for principal authorization2013 FormatThe system MAY provide the ability to define context for the purpose of principal authorization based on identity, role, work assignment, present condition, location, patient consent, or patient's present conditionSecurity and ConfidentialityNormative Statementsno
Req-558Ability to document limitations on the patient's parents' level of authority2013 FormatThe system SHALL provide the ability to document limitations on the patient's parents' level of authority to make decisions on behalf of the patient or access health information about the patient.Security and ConfidentialityNormative Statementsno
Req-559Ability to document parental (guardian) notification or permission2013 FormatThe system SHALL provide the ability to document parental (guardian notification or permission for consenting minors to receive some treatments as required by institutional policy or jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-552Determine need for minor patient consent for outside access to content2013 FormatThe system MAY determine the need for minor patient consent to permit outside access to content based on determination of age of majority within a legal jurisdiction, possibly in combination with record content to be accessed.Security and ConfidentialityNormative Statementsno
Req-573Entity Authorization.2013 Format
STATEMENT: Manage the sets of access-control permissions granted to entities that use an EHR-S (EHR-S Users
Enable EHR-S security administrators to grant authorizations to users, for roles, and within contexts. A combination of these authorization...
STATEMENT: Manage the sets of access-control permissions granted to entities that use an EHR-S (EHR-S Users
Enable EHR-S security administrators to grant authorizations to users, for roles, and within contexts. A combination of these authorization categories may be applied to control access to EHR-S functions or data within an EHR-S, including at the application or the operating system level.

DESCRIPTION: EHR S Users are authorized to use the components of an EHR-S according to their identity, role, work-assignment, location and/or the patient's present condition and the EHR S User's scope of practice within a legal jurisdiction.
- User based authorization refers to the permissions granted or denied based on the identity of an individual. An example of User based authorization is a patient defined denial of access to all or part of a record to a particular party for privacy related reasons. Another user based authorization is for a tele-monitor device or robotic access to an EHR-S for prescribed directions and other input.
- Role based authorization refers to the responsibility or function performed in a particular operation or process. Example roles include: an application or device (tele-monitor or robotic or a nurse, dietician, administrator, legal guardian, and auditor.
- Context-based Authorization is defined by ISO 10181-3 Technical Framework for Access Control Standard as security-relevant properties of the context in which an access request occurs, explicitly time, location, route of access, and quality of authentication. For example, an EHR-S might only allow supervising providers' context authorization to attest to entries proposed by residents under their supervision.
In addition to the ISO standard, context authorization for an EHR-S is extended to satisfy special circumstances such as, work assignment, patient consents and authorizations, or other healthcare-related factors. A context-based example is a patient-granted authorization to a specific third party for a limited period to view specific EHR records.
Another example is a right granted for a limited period to view those, and only those, EHR records connected to a specific topic of investigation.
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Security and ConfidentialityFunctionno
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