United States Health Information Knowledgebase

 

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.

remove Filtering Release Package on 2013 Format
MS Excel
Download as an MS Excel spreadsheet.
[Download Excel ReaderExit Disclaimer]
PDF
Download as a PDF file.
[Download PDF ReaderExit Disclaimer]
MS Word
Download as an MS Word document.
[Download Word ReaderExit Disclaimer]
Remove All Filters

sort Req ID
sort Title
sort Release Package
Release Package(s) Selected
sort Description
sort Topic Area
Topic Area(s) Selected
sort Type
Type(s) Selected
sort Critical/Core
Critical/Core(s) Selected
Req-965Additional quality measures2013 Format
The system SHOULD be able to capture, retrieve, export, and display codified data for user-defined or other endorsed quality measures, such as National Quality Forum (NQF Physician Quality Reporting System (PQRS, formerly known as the...
The system SHOULD be able to capture, retrieve, export, and display codified data for user-defined or other endorsed quality measures, such as National Quality Forum (NQF Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Initiative National Association of Children's Hospitals and Related Institutions (NACHRI National Initiative for Children's Healthcare Quality (NICHQ or state-endorsed. This includes "numerator" elements (e.g., the number of times that a particular service was delivered and "denominator" elements (e.g., the size of the population that should receive the service of interest within a user-specified time frame.
Show Full Text
Quality MeasuresNormative Statementsno
Req-967Display quality measures graphically2013 FormatThe system SHALL be able to display the quality measures graphically, with multiple time points as selected by the user within the healthcare setting (e.g., run chartsQuality MeasuresNormative Statementsno
Req-972Age-specific preventive encounters2013 FormatThe system SHALL support age-specific preventive well-child encounters with content based on age-appropriate recommendations such as Medicaid EPSDT (Early and Periodic Screening, Diagnostic & Treatment and Bright Futures periodicity schedules.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-973Monitor compliance with recommended periodicity of visits2013 FormatThe system SHALL monitor and report on compliance with the recommended locally adopted periodicity of visits and be able to identify individuals who have not attended recommended health supervision visits.Well Child/Preventive CareNormative Statementsyes
Req-974Record age-appropriate interim/initial history2013 FormatThe system SHALL enable users to record an age-appropriate interim/initial history as cited in an accepted source.Well Child/Preventive CareNormative Statementsno
Req-975Record well-child data elements independently2013 FormatThe system SHOULD record values for an accepted list of well-child data elements in a way that enables them to be retrieved independent of other history.Well Child/Preventive CareNormative Statementsno
Req-976Record well-child data elements2013 FormatThe system MAY record values for an accepted list of well-child data elements through locally structured sets of values.Well Child/Preventive CareNormative Statementsno
Req-977Blood pressure norms2013 FormatThe system SHALL provide age-, gender-, and height-specific norms and percentiles for blood pressure measurements.Well Child/Preventive CareNormative Statementsyes
Req-978Physical exam screening results2013 FormatThe system SHALL allow documentation of the presence or absence of age- and gender-specific physical exam findings.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-979Record age-appropriate preventive procedures2013 FormatThe system SHALL enable users to record age-appropriate preventive procedures as specified in an accepted source.Well Child/Preventive CareNormative Statementsno
Req-980Record preventive procedures independently2013 FormatThe system SHALL record values for age-appropriate preventive procedures in a way that enables them to be retrieved independent of other history.Well Child/Preventive CareNormative Statementsno
Req-981Record locally structured values for preventive procedures2013 FormatThe system MAY record values for age-appropriate preventive procedures through locally structured sets of values.Well Child/Preventive CareNormative Statementsno
Req-983Prompts for re-screening2013 FormatThe system SHOULD provide prompts regarding re-screening.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-984Record age-appropriate Anticipatory Guidance2013 FormatThe system SHALL enable users to record age-appropriate anticipatory guidance as specified in an accepted source.Well Child/Preventive CareNormative Statementsno
Req-985Record Anticipatory Guidance independently2013 FormatThe system SHOULD record values for anticipatory guidance in a way that enables the history of provision of guidance to be retrieved (individually and collectively independent of other history, subject to practice preferences.Well Child/Preventive CareNormative Statementsno
Req-986Record Anticipatory Guidance through locally structured values2013 FormatThe system SHOULD record values for anticipatory guidance through locally structured sets of values, enabling additional or modified guidance.Well Child/Preventive CareNormative Statementsno
Req-987Summary forms for non-clinicians2013 FormatThe system SHOULD provide a summary of immunizations, screenings, measurements, physical exam findings, problems, medications, allergies via paper (e.g. "School/Camp Form" or other mechanism (e.g. electronically to non-clinical resources in need of clinical information regarding the child.Well Child/Preventive CareNormative Statementsno
Req-988Age-specific ROS2013 FormatIf Review of Systems (ROS is composed of structured data then it SHALL allow age-specific content.Well Child/Preventive CareNormative Statementsno
Req-989Birth Demographics2013 FormatIn either single or multiple births the mother's demographics, except for name, are associated with the child. Additionally, the names initially given the baby(ies may be simply "Baby 1," "Baby 2," etc.Patient IdentifierHeaderno
Req-990Unique newborn identifiers2013 FormatThe system SHALL generate a unique identifier for each newborn.Patient IdentifierNormative Statementsno
Req-991Temporary newborn names2013 FormatThe system SHALL be able to record temporary names such as "Baby 1" to "Baby N".Patient IdentifierNormative Statementsno
Req-992Associate mother’s demographics with newborn2013 FormatThe system SHALL provide the ability to associate elements of the mother's demographic information, aside from name and other personal identifiers, with each baby in the single or multiple birth situation.
Example: Street address, telephone number, email address but NOT mother's date of birth, driver's license, etc.
Patient IdentifierNormative Statementsno
Req-993Updates to temporary names/demographics2013 FormatThe system SHALL enable updates to demographic information such as replacing the temporary names "Baby 1" to "Baby N" with the actual names, as well as other demographic information, when available.

See Req-992 for demographic information examples.
Patient IdentifierNormative Statementsno
Req-1005Link maternal and birth data to child health record2013 FormatThe system SHALL provide for the linking of maternal and birth data to the child health record for quality measures. Examples: linkage of frequency of prenatal care to birth weight.Quality MeasuresNormative Statementsyes
Req-1006Support prescription details2013 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.
Medication ManagementNormative Statementsno
Req-1007Copy and paste selected information from another medical record/chart2013 Format
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL...
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL support suppression of the maternal identity in cases that require parental confidentiality (e.g. voluntary surrender for adoption, or removal from the mother's care for other reasons
Show Full Text
Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-1008Manage Data Associated with Breast Milk Storage and Administration2013 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.
Well Child/Preventive CareFunctionno
Req-1009Manage data associated with breast milk products2013 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.
Well Child/Preventive CareNormative 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-1013Standard terminology for medications and treatments2013 Format
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use...
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use existing terminologies that represent clinical medications, such as MediSpan, First Data Bank or Multum to support this function. However, EHR systems may also maintain their own proprietary medication terminology. In either case, the scope of the functionality for EHR systems relates to their ability to allow users to encode medications according to a standard representation.
Show Full Text
Medication Management, 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.
Show Full Text
Special Terminology and InformationNormative Statementsno
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
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-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.
Show Full Text
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
Scroll To Top