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Req-745Support for Accurate Specimen Collection2013 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.
Primary Care Management, Well Child/Preventive CareFunctionno
Req-1068Minimum required data in summary2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1163Transition of medical records2013 FormatThe system SHOULD support transition of medical records from pediatric to adult care.Primary Care Management, 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-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-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-271Support for Research Protocols Relative to Individual Patient Care2013 FormatSTATEMENT: Provide support for the management of patients enrolled in research protocols.
DESCRIPTION: The clinician is presented with appropriate protocols for patients participating in research studies, and is supported in the management and tracking of study participants.
Primary Care ManagementFunctionno
Req-485Incorporate scanned documents2013 FormatThe system SHALL provide the ability to incorporate and index scanned documents from internal and external providers or agencies into the patient record.Primary Care ManagementNormative Statementsno
Req-481Capture and communicate referrals2013 FormatThe system SHALL provide the ability to capture and communicate referral(s to other care provider (s or agencies, whether internal or external to the organization.Primary Care ManagementNormative Statementsno
Req-480Create detailed referral orders2013 FormatThe system SHALL provide the ability to create referral orders with detail adequate for correct routing, including referrals to outside agencies or providers.Primary Care ManagementNormative Statementsno
Req-483Transmit data with referral2013 FormatThe system SHOULD allow clinical and administrative data, and test and procedure results to be transmitted with or following a referral.Primary Care ManagementNormative Statementsno
Req-614Acknowledge receipt of new results2013 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.
Primary Care ManagementNormative Statementsno
Req-613New results notification2013 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.
Primary Care ManagementNormative Statementsno
Req-644Clinical data for research study participants2013 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.
Primary Care ManagementNormative Statementsno
Req-798Referral completion capture2013 FormatThe system SHOULD provide the ability to capture completion of a referral appointment.Primary Care ManagementNormative Statementsno
Req-1165Transition of self care from pediatric to adult care2013 FormatThe system SHOULD support transition of care from pediatric to adult care in regards to self-care management and care planning.Primary Care ManagementNormative Statementsno
Req-1167National guidelines for disease-specific management2013 FormatThe system SHOULD incorporate national guidelines for disease-specific management and allow update, e.g. for shared-decision-making (SDM national guidelines for patients with attention deficit hyperactive disorder (ADHD and asthma diagnosis and management for pediatric patients.Primary Care ManagementNormative Statementsno
Req-1166Clinical decision support tools2013 FormatThe system SHOULD incorporate clinical decision support tools and utilities that support severity assessment and mortality prediction, a minimum data set, standardized terminology, and validated indicators for such common chronic diseases as asthma.Primary Care ManagementNormative Statementsno
Req-1168Age-specific protocols2013 FormatThe system SHOULD provide for the management and inclusion of protocols that can be differentiated and implemented based on patient age. For example, fever work-up for patients less than 28 days old, vs. fever work-up for patients greater than 28 days old but less than 90 days old.Primary Care ManagementNormative Statementsno
Req-1169Transition of care coordination from pediatric to adult care2013 FormatThe system SHOULD support transition of care from pediatric to adult care in regards to coordination of care.Primary Care ManagementNormative Statementsno
Req-1170Chronic disease and age-specific educational materials2013 FormatThe system SHOULD incorporate chronic disease and age-specific educational materials, for example diabetes and asthma.Primary Care ManagementNormative Statementsno
Req-1171Document acute primary care education2013 FormatThe system SHOULD provide the ability to document that acute primary care education was provided to parents, guardian, patient, or other caregivers.Primary Care ManagementNormative Statementsno
Req-1172Age-based educational cues2013 FormatThe system SHOULD provide age-based educational cues for healthcare providers and patients. For example, the system MAY implement age-based educational materials provided by the American Academy of Pediatrics' Bright Futures toolkit.Primary Care ManagementNormative 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-1174Communication during care and follow-up care2013 FormatThe system SHALL incorporate support communication during care and follow-up care and communication of data between different disciplines.

Example: A system can support communication with school nurses, day care providers and other professional caregivers.
Primary Care ManagementNormative 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-1150Electronically import maternal data into patient history2013 FormatWhen electronic access to the mother's data is possible, the system SHALL enable incorporation of selected maternal prenatal and perinatal data into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1149Legal constraints on importing maternal data2013 FormatThe system SHALL follow applicable state or federal privacy laws regarding the importation of maternal information into the child's record.Prenatal ScreeningNormative Statementsno
Req-1153Distinguish maternal from child data2013 FormatWithin the child's record the system SHALL clearly distinguish maternal history data from directly collected child data.Prenatal ScreeningNormative Statementsno
Req-1152Electronically import maternal data from multiple sources2013 FormatWhen the maternal prenatal and perinatal record is split across more than one system (e.g. prenatal care and Labor & Delivery and if electronic access is possible, the system SHOULD enable incorporation of maternal information from each of those systems into the child's record.Prenatal ScreeningNormative Statementsno
Req-1155Maternal infections that impact the newborn2013 FormatThe system SHALL capture other maternal infections that can affect the newborn in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative 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-1157Capture maternal problem list2013 FormatThe system SHALL enable selective capture into the child's chart of the maternal problem list by the child's healthcare provider.Prenatal ScreeningNormative 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-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-1158Preserve codification of maternal data2013 FormatMaternal data, when captured into the child's chart, SHOULD preserve codification when codified in the maternal chart.Prenatal 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-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-1162Capture data that precedes the newborn’s record2013 FormatThe system SHALL allow capture of data that were collected for a newborn before the newborn's electronic record was created.Prenatal ScreeningNormative Statementsyes
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-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-1095Transferrable access authority2013 FormatThe system SHALL provide a mechanism to enable access control that allows a transferrable access authority.Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityNormative Statementsno
Req-560Capture Patient-Originated Data2013 Format
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish...
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish patient-originated data that is either provided or entered by a patient from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-originated data intended for use by providers will be available for their use.
Data about the patient may be appropriately provided by:
1. the patient
2. a surrogate (parent, spouse, guardian or
3. an informant (teacher, lawyer, case worker
An electronic health record may provide the ability for direct data entry by any of these.
Patient-originated data may also be captured by devices and transmitted for inclusion into the electronic health record.
Data entered by any of these must be stored with source information. A provider must authenticate patient-originated data included in the patient's legal health record.
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Patient Portals - PHRFunctionno
Req-524Incorporate and adhere to legal local and national laws in regards to patient EHR access2013 FormatThe system SHALL incorporate and adhere to local, state, and national laws in regards to patient EHR access (e.g. children under 12 cannot sign up for access to their own accountPatient Portals - PHRNormative Statementsno
Req-525Ability to allow parents/legal guardians and children add any relevant additional health information2013 FormatThe system SHOULD allow parents/legal guardians and children of appropriate age to add any relevant additional health information and fill in gaps in their EHR.Patient Portals - PHRNormative Statementsno
Req-523Measures to verify identity of parent/guardian2013 FormatThe system SHOULD incorporate measures that confirm/verify the identity of the parent/s or guardian/s and their relationship to a child.Patient Portals - PHRNormative Statementsno
Req-1100Display appropriate EHR information to parents and guardians2013 FormatThe system SHOULD enable parents and caregivers to see appropriate information in the electronic health record, including decisions made and, when possible, the clinical rationale for those decisions.Patient Portals - PHRNormative Statementsno
Req-1101School-based care delivery data2013 FormatThe system MAY enable controlled access to and display of school based care delivery data.Patient Portals - PHRNormative Statementsno
Req-1096Distinguish patient sourced data2013 FormatThe system SHALL clearly distinguish patient sourced/entered data from data received from a clinical system.Patient Portals - PHRNormative Statementsno
Req-1098Multiple views of child data2013 Format
The system SHALL provide multiple views of the child's data, including views for patients and adult caregivers.
Example: The system may have multiple views of the same data, e.g., a clinician view, an adult caregiver...
The system SHALL provide multiple views of the child's data, including views for patients and adult caregivers.
Example: The system may have multiple views of the same data, e.g., a clinician view, an adult caregiver view, and a child view. The data in the source system (EHR must be structured in a manner that permits parents and caregivers to view and understand the extent to which the care their children receive is clinically appropriate and of high quality.
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Patient Portals - PHRNormative Statementsno
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