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Req-89Prompts for local neonatal screening2013 FormatThe system SHALL have the ability to prompt the care provider to perform all locally required neonatal screening tests.Newborn ScreeningNormative Statementsno
Req-90Neonatal screening education2013 FormatThe system SHOULD provide prompting, documentation of teaching, and education materials about neonatal screening for parents and guardians.Newborn ScreeningNormative Statementsno
Req-93Birth date format2013 FormatThe system SHALL record Birth Date (MM:DD:YYYYBirth InformationNormative Statementsno
Req-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
Req-95Link maternal and birth data to child health record2013 FormatThe system SHALL provide for the linking or recording of maternal and birth data to the child health record. Examples: maternal social history, maternal prenatal results, and gravida/para (GPBirth InformationNormative 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
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-100Geographic locations visited2013 FormatThe system SHOULD record geographic areas visited by the patient for use in cases of vector-borne epidemiology.Well Child/Preventive CareNormative Statementsno
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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Headerno
Req-104Data and Documentation From External Sources2013 FormatExternal sources are those outside the EHR system, including clinical, administrative, and financial information systems, other EHR systems, PHR systems, and data received through health information exchange networks.Birth Information, Parents and Guardians and Family Relationship Data, Patient Portals - PHRHeaderno
Req-106Record Management2013 Format
For those functions related to data capture, data may be captured using standardized code sets or nomenclature, depending on the nature of the data, or captured as unstructured data. Care-setting dependent data is entered by...
For those functions related to data capture, data may be captured using standardized code sets or nomenclature, depending on the nature of the data, or captured as unstructured data. Care-setting dependent data is entered by a variety of caregivers. Details of who entered data and when it was captured should be tracked. Data may also be captured from devices or other tele-health applications.
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Birth Information, Child Welfare, Genetic information, Growth Data, Immunizations, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals...
Birth Information, Child Welfare, Genetic information, Growth Data, Immunizations, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, Primary Care Management, Well Child/Preventive Care
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Headerno
Req-107Standards Based Interoperability2013 Format
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified...
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified view of the system where the reality is that several disparate systems may be coming together.
Interoperability standards also enable the sharing of information between EHR systems, including the participation in regional, national, or international information exchanges.
Timely and efficient access to information and capture of information is promoted with minimal impact to the user.
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Immunizations, Prenatal Screening, Registry Linkages, School-Based LinkagesHeaderno
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-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-110Capture patient vital signs2013 Format
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Growth DataNormative Statementsyes
Req-111Statistics for growth chart data2013 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.
Growth DataNormative Statementsno
Req-112Normative values for growth chart data2013 FormatThe system SHOULD calculate and display average weight for age, average height for age, and ideal/target weight for height (e.g. Waterlow methodGrowth DataNormative Statementsno
Req-113Indicate information collected at Point of Care2013 FormatThe system SHOULD indicate point of care of collected measures and/or allow filtering of values by point(s of care.Growth DataNormative Statementsno
Req-115Childhood obesity statistics2013 FormatSystem MAY store and display waist circumference and hip circumference and calculate/display waist to hip ratio in patients identified with obesity or cardiovascular risk.Growth DataNormative Statementsno
Req-116Select growth data reference standards2013 FormatThe system SHALL allow user selection of appropriate reference standards (e.g. CDC, WHO, Down's, or Turner's Syndrome display corresponding growth reference percentile curves/calculations, and denote the growth reference used in calculation and display.Growth DataNormative Statementsyes
Req-117Calculate growth velocity2013 FormatThe system SHOULD calculate growth velocity between two points on the growth chart selected by the user.Growth DataNormative Statementsno
Req-118Support for growth data assessment and planning2013 FormatThe system SHOULD provide access to display and print accepted anthropometry procedure standards/training; provider/layperson growth chart interpretation guides; and related disease management guidelines.Growth DataNormative Statementsno
Req-119Documentation for patient educational material2013 FormatThe system SHALL provide the ability to document that the educational material was reviewed with the patient and/or patient representative and their comprehension of the material.Growth DataNormative Statementsno
Req-120Immediate alerts for abnormal growth values2013 FormatThe system SHALL support alerting at the time of value entry for values outside of the probable range and heights less than previous measures.Growth DataNormative Statementsno
Req-121View new data on growth chart before confirming2013 FormatUser MAY be able to view values being entered plotted on growth chart prior committing to system.Growth DataNormative Statementsno
Req-122Manage Patient Clinical Measurements2013 Format
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of...
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of care. Other clinical measures (such as expiratory flow rate, size of lesion, etc. are captured and managed, and may be discrete data.
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EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive CareFunctionno
Req-123Patient, Family and Care Giver Education2013 Format
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in...
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in the language or dialect understood by the patient or representative. Material should be at the level of the patient or representative's level of understanding and sensory capability. Special needs are documented. Material may be disseminated via a mode available to and acceptable by the patient e.g., printed, electronically or otherwise. The review of material between the clinician and the patient, and the patient's understanding of the review, is documented when desired by the clinician. The patient or patient's representatives are able to obtain educational information independently without formal review with the clinician if desired.
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Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-124Support for Identification of Potential Problems and Trends2013 Format
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab...
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab results it is important to be able to identify potential problems and trends that may be patient-specific, given the individual's personal health profile, or changes warranting further assessment. For example: significant trends (lab results, weight a decrease in creatinine clearance for a patient on metformin, an abnormal increase in INR for a patient on warfarin, an increase in suicidal ideation; presence of methamphetamines; or absence of therapeutic levels of antidepressants.
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Well Child/Preventive CareFunctionno
Req-125Capture Data and Documentation from External Clinical Sources2013 FormatIncorporate clinical data and documentation from external sources. Mechanisms for incorporating external clinical data and documentation (including identification of source such as image documents and other clinically relevant data are available. Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate.Birth InformationFunctionno
Req-126Growth and body composition data2013 FormatSystem supports recording of growth and body composition measures, calculations, conversions, normal ranges, and trending.Growth DataHeaderno
Req-128Manage Patient Demographics2013 Format
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth,...
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, time of birth, gestation, gender, and other information is stored and maintained for unique patient identification, reporting purposes and for the provision of care. Patient demographics are captured and maintained as discrete fields (e.g., patient names and addresses and may be enumerated, numeric or codified. Key patient identifiers are shown on all patient information output (such as name and ID# on each screen of a patient's record The system will track who updates demographic information, and when the demographic information is updated.
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Birth Information, Child Welfare, Genetic information, Growth Data, Patient Identifier, Prenatal Screening, Well Child/Preventive CareFunctionno
Req-129Present Alerts for Preventive Services and Wellness2013 Format
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider...
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider or patient is presented with due or overdue activities based on protocols for preventive care and wellness. Examples include but are not limited to, routine immunizations, adult and well child care, age and gender appropriate screening exams, such as PAP smears. The provider may wish to provide reminders to the patient based on the alert.
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EPSDT, Newborn Screening, Well Child/Preventive CareFunctionno
Req-248Capture Patient Health Data Derived from Administrative and Financial Data and Documentation2013 Format
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data...
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data derived from administrative or financial data from clinically authenticated data. Sources of administrative and financial data relating to a patient's health may provide this data for entry into the health record or be given a mechanism for entering this data directly. The data must be explicitly labeled as derived from administrative or financial data, and information about the source must be linked with that data. Patient health data that is derived from administrative or financial data may be provided by:
1. the patient
2. a provider
3. a payer, or
4. entities that transmit or process administrative or financial data.
Since this data is non-clinical, it may not be authenticated for inclusion in the patient's legal health record. Registration data, which may contain demographic data and pertinent positive and negative histories, is an example of administrative and financial data that may be captured.
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Parents and Guardians and Family Relationship DataFunctionno
Req-249Health Record Output2013 Format
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare...
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare process, supports selection of specific sections of the health record, and allows healthcare organizations to define the report and/or documents that will comprise the formal health record for disclosure purposes. A mechanism should be provided for both chronological and specified record element output. This may include defined reporting groups (i.e. print sets For example: Print Set A = Patient Demographics, History & Physical, Consultation Reports, and Discharge Summaries. Print Set B = all information created by one caregiver. Print Set C = all information from a specified encounter. An auditable record of these requests and associated exports may be maintained by the system. This record could be implemented in any way that would allow the who, what, why and when of a request and export to be recoverable for review. The system has the capability of providing a report or accounting of disclosures by patient that meets in accordance with scope of practice, organizational policy and jurisdictional law.
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Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, 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-251Health Service Reports at the Conclusion of an Episode of Care2013 Format
STATEMENT: Support the creation of health service reports at the conclusion of an episode of care. Support the creation of health service reports to authorized health entities, for example public health, such as notifiable condition...
STATEMENT: Support the creation of health service reports at the conclusion of an episode of care. Support the creation of health service reports to authorized health entities, for example public health, such as notifiable condition reports, immunization, cancer registry and discharge data that a provider may be required to generate at the conclusion of an episode of care.
DESCRIPTION: Effective use of this function means that providers do not perform additional data entry to support health management programs and reporting.
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Registry LinkagesFunctionno
Req-252Administrative Transaction Processing2013 Format
STATEMENT: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
DESCRIPTION: Support the creation...
STATEMENT: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
DESCRIPTION: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
· The EHR system shall capture the patient health-related information needed for administrative and financial purposes including reimbursement.
· Captures the episode and encounter information to pass to administrative or financial processes (e.g. triggers transmissions of charge transactions as by-product of on-line interaction including order entry, order statusing, result entry, documentation entry, medication administration charting
· Automatically retrieves information needed to verify coverage and medical necessity.
· As a byproduct of care delivery and documentation: captures and presents all patient information needed to support coding. Ideally performs coding based on documentation.
· Clinically automated revenue cycle - examples of reduced denials and error rates in claims.
· Clinical information needed for billing is available on the date of service.
· Physician and clinical teams do not perform additional data entry / tasks exclusively to support administrative or financial processes.
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Registry LinkagesFunctionno
Req-253Manage Allergy, Intolerance and Adverse Reaction List2013 Format
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates,...
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s includes all reactions including those that are classifiable as a true allergy, intolerance, side effect or other adverse reaction to drug, dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are maintained.
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Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive CareFunctionno
Req-254Manage Assessments2013 Format
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the...
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the patient, such as growth charts, developmental profiles, and disease specific assessments. Wherever possible, this assessment should follow industry standard protocols although, for example, an assessment for an infant will have different content than one for an elderly patient. When a specific standard assessment does not exist, a unique assessment can be created, using the format and data elements of similar standard assessments whenever possible.
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Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care...
Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care Management, Registry Linkages, Special Terminology and Information, Well Child/Preventive Care
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Functionno
Req-255Manage Clinical Documents and Notes2013 Format
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on...
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphical, audio, etc.. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-256Manage Consents and Authorizations2013 Format
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment...
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
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Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Functionno
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-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-259Manage Medication List2013 Format
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start,...
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.
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Medication ManagementFunctionno
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-262Manage Patient-Specific Care and Treatment Plans2013 Format
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the...
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
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Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareFunctionno
Req-263Manage Problem List2013 Format
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists...
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of historical information and tracking the changing character of problem(s and their priority. The source (e.g. the provider, the system id, or the patient of the updates should be documented. In addition all pertinent dates are stored. All pertinent dates are stored, including date noted or diagnosed, dates of any changes in problem specification or prioritization, and date of resolution. This might include time stamps, where useful and appropriate. The entire problem history for any problem in the list is viewable.
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Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareFunctionno
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-265Notifications and Reminders for Preventive Services and Wellness2013 Format
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are...
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are due or overdue and these communications can be captured. Examples include but are not limited to time sensitive patient and provider notification of: follow-up appointments, laboratory tests, immunizations or examinations. The notifications can be customized in terms of timing, repetitions and administration reports. E.g. a PAP test reminder might be sent to the patient two months prior to the test being due, repeated at three month intervals, and then reported to the administrator or clinician when nine months overdue.
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EPSDT, Newborn Screening, Patient Portals - PHR, Well Child/Preventive CareFunctionno
Req-266Present Ad Hoc Views of the Health Record2013 Format
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters,...
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
DESCRIPTION: A key feature of an electronic health record is its ability to support the delivery of care by enabling prior information to be found and meaningfully displayed. EHR systems should facilitate search, filtering, summarization, and presentation of available data needed for patient care. Systems should enable views to be customized, for example, specific data may be organized chronologically, by clinical category, or by consultant, depending on need. Jurisdictional laws and organizational policies that prohibit certain users from accessing certain patient information must be supported.
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Immunizations, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareFunctionno
Req-267Produce a Summary Record of Care2013 Format
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of...
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of care. Create service reports at the completion of an episode of care such as, but not limited to, discharge summaries and public health reports, without additional input from clinicians.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-268Manage Patient History2013 Format
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient...
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.
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Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening,...
Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening, Primary Care Management, Security and Confidentiality, Specialized Scales/Scoring, Well Child/Preventive Care
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Functionno
Req-269Support for Standard Care Plans, Guidelines, Protocols2013 Format
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and...
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported.
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EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
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-272Support for Patient Specific Dosing and Warnings2013 Format
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g....
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g. pregnancy, breast-feeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, height, weight, and body surface area (BSA shall also be incorporated.
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Immunizations, Medication ManagementFunctionno
Req-273Support for Medication and Immunization Administration2013 Format
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To...
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a by-product of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured.
Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the "window" for timely administration of medications.
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Immunizations, Medication Management, Registry LinkagesFunctionno
Req-274Patient Privacy and Confidentiality2013 Format
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of...
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of EHRs are violated if access to EHRs occurs without authorization. Violations or potential violations can impose tangible economic or social losses on affected patients, as well as less tangible feelings of vulnerability and pain. Fear of potential violations discourages patients from revealing sensitive personal information that may be relevant to diagnostic and treatment services. Rules for the protection of privacy and confidentiality may vary depending upon the vulnerability of patients and the sensitivity of records. Strongest protections should apply to the records of minors and the records of patients with stigmatized conditions. Authorization to access the most sensitive parts of an EHR is most definitive if made by the explicit and specific consent of the patient. Please see the definition of masking in the glossary.
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Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
Req-275Auditable Records2013 Format
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time...
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time stamping implies the ability to indicate the time zone where it was recorded (time zones are described in ISO 8601 Standard Time Reference Auditable records extend to information exchange, to audit of consent status management (to support Req-256 (HL7 ID: DC.1.3.3 and to entity authentication attempts. Audit functionality includes the ability to generate audit reports and to interactively view change history for individual health records or for an EHR-S.
DESCRIPTION: Audit functionality extends to security audits, data audits, audits of data exchange, and the ability to generate audit reports. Audit capability settings should be configurable to meet the needs of local policies. Examples of audited areas include:
- Security audit, which logs access attempts and resource usage including user login, file access, other various activities, and whether any actual or attempted security violations occurred
- Data audit, which records who, when, and by which system an EHR record was created, updated, translated, viewed, extracted, or (if local policy permits deleted. Audit-data may refer to system setup data or to clinical and patient management data
- Information exchange audit, which records data exchanges between EHR-S applications (for example, sending application; the nature, history, and content of the information exchanged and information about data transformations (for example, vocabulary translations, reception event details, etc.
- Audit reports should be flexible and address various users' needs. For example, a legal authority may want to know how many patients a given healthcare provider treated while the provider's license was suspended. Similarly, in some cases a report detailing all those who modified or viewed a certain patient record
- Security audit trails and data audit trails are used to verify enforcement of business, data integrity, security, and access-control rules
-There is a requirement for system audit trails for the following events:
>Loading new versions of, or changes to, the clinical system;
>Loading new versions of codes and knowledge bases;
>Taking and restoring of backup;
>Changing the date and time where the clinical system allows this to be done;
>Archiving any data;
>Re-activating of an archived patient record;
>Entry to and exiting from the clinical system;
>Remote access connections including those for system support and maintenance activities
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Growth DataFunctionno
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-277Registry Notification2013 Format
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal...
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal health information to disease specific registries, other notifiable registries such as immunization registries, through standard data transfer protocols or messages. The user can update and configure communication for new registries.
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Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
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-279Support Clinical Communication2013 Format
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs...
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs of healthcare-related communications, and provides automatic tracking and reporting. The list of communication participants is determined by the care setting and may change over time. Because of concerns about scalability of the specification over time, communication participants for all care settings or across care settings are not enumerated here because it would limit the possibilities available to each care setting and implementation. However, communication between providers and between patients and providers will be supported in all appropriate care settings and across care settings. Implementation of the EHRS enables new and more effective channels of communication, significantly improving efficiency and patient care. The communication functions of the EHRS will eventually change the way participants collaborate and distribute the work of patient care.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
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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Headerno
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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Headerno
Req-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, 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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Headerno
Req-285Administrative and Financial2013 FormatSystem supports Administrative and Financial functions.Children with Special Healthcare Needs, Genetic information, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
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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Headerno
Req-287Preferences, Directives, Consents and Authorizations2013 FormatMaintain preferences, directives, consents and authorizations.
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Headerno
Req-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-290Support for Condition Based Care and Treatment Plans, Guidelines, Protocols2013 FormatSystem supports Condition Based Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-291Care and Treatment Plans, Guidelines and Protocols2013 FormatSystem maintains Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-292Support for Medication and Immunization Ordering2013 FormatSystem supports Medication and Immunization Ordering.Immunizations, Medication ManagementHeaderno
Req-293Medication and Immunization Management2013 FormatSystem manages Medications and ImmunizationsImmunizations, Medication Management, Registry LinkagesHeaderno
Req-294Security2013 Format
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce...
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce security, all EHR-S applications must adhere to the rules established to control access and protect the privacy of EHR information. Security measures assist in preventing unauthorized use of data and protect against loss, tampering and destruction. An EHR-S must be capable of including or interfacing with standards-conformant security services to ensure that any Principal (user, organization, device, application, component, or object accessing the system or its data is appropriately authenticated, authorized and audited in conformance with local and/or jurisdictional policies.

An EHR-S should support Chains of Trust in respect of authentication, authorization, and privilege management, either intrinsically or by interfacing with relevant external services.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security...
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security and Confidentiality
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Headerno
Req-295Health Record Information and Management2013 Format
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to...
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to clinical documents. Ensure that information entered by or on behalf of the patient is accurately represented.
DESCRIPTION: Since EHR information will typically be available on a variety of EHR-S applications, an EHR-S must provide the ability to access, manage and verify accuracy and completeness of EHR information, maintain the integrity and reliability of the data, and provide the ability to audit the use of and access to EHR information.
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Growth Data, Prenatal Screening, Well Child/Preventive CareHeaderno
Req-296Standard Terminologies and Terminology Services2013 Format
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated...
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated by the consistency of human and machine interpretation of shared data and reports. It includes the capture and support of consistent data for templates and decision support logic.

Terminology standards pertain to concepts, representations, synonyms, relationships and computable (machine-readable definitions. Terminology services provide a common way for managing and retrieving these items.
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Medication Management, Special Terminology and InformationHeaderno
Req-297Clinical Support2013 FormatSystem provides Clinical Support.
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well...
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-426Provide unit conversions calculation and display during data entry and display2013 FormatThe system SHALL provide unit conversions calculation and display during data entry and display (e.g. lbs/kgGrowth DataNormative Statementsno
Req-429Screening tool status2013 FormatThe system SHALL capture the administration, completion, and evaluation of screening tools.Well Child/Preventive CareNormative Statementsno
Req-434Targeted patient education materials after screening2013 FormatThe system SHOULD provide access to targeted patient education materials when screening triggers specialist or early-intervention program referral.Well Child/Preventive CareNormative Statementsno
Req-443Integrated immunizations reporting2013 FormatThe EHR SHOULD allow an integrated view of what immunizations are due or past due.ImmunizationsNormative Statementsno
Req-451Closest available standardized dose2013 FormatThe system MAY inform the ordering provider about the closest available standardized dose after calculating the dose based on patient age and weight.Medication ManagementNormative 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-456Support the capture of coded age based, disease specific measures2013 FormatThe system SHALL support the capture of coded age based, disease specific measures used in the characterization and/or categorization of disease severity (e.g. Asthma: National Heart Lung and Blood Institute Asthma Severity Tool; depression; ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-457Support the capture of coded pediatric functional health status measures2013 FormatThe system SHALL support the capture of coded pediatric functional health status measures (e.g. ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-458Coded disease measure goals and thresholds2013 FormatThe system SHOULD capture/calculate coded individualized disease measure goals and thresholds for modifying care (e.g. peak flow, FEV1, HgA1c, or behavioral goals used in self-care and inpatient treatment plansChildren with Special Healthcare Needs, Primary Care Management, Quality MeasuresNormative Statementsno
Req-461Support the addition or exclusion of patients from registries by authorized users2013 FormatThe system SHOULD support the addition or exclusion of patients from registries by authorized users and capture addition or exclusion criteria.Children with Special Healthcare NeedsNormative Statementsno
Req-471Access to patient data-specific materials2013 FormatThe system SHOULD provide access to display and print relevant provider/layperson treatment procedure standards/training; medical/psychological/behavioral condition education materials; and related management guidelines based on coded patient data in the system (e.g. InfobuttonChildren with Special Healthcare Needs, Patient Portals - PHRNormative Statementsno
Req-472Communicate with local service registries2013 FormatThe system SHOULD provide the ability to search, view, and contribute to local service registries that include providers, medical home practices or services, durable medical equipment (DME skilled nursing facilities (SNF social service programs, etc. and detail services, insurance affiliation, and preferred contact method for notes, referrals, and orders.Children with Special Healthcare NeedsNormative 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-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-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-484Document communication with providers or agencies2013 FormatThe system SHALL provide the ability to document in the patient record verbal/telephone communication with providers or agencies whether internal or external to the organization.Child Welfare, Primary Care ManagementNormative Statementsno
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-486Ability to prompt for frequent monitoring of specific scales and scores2013 FormatThe system SHALL prompt for frequent monitoring of specific scales and scores that have a dynamic nature, including step-wise scales that assess the response to increasingly noxious stimuli to define levels of consciousness.Specialized Scales/ScoringNormative Statementsno
Req-488Incorporate scale and score tools2013 FormatThe system SHOULD incorporate scale and score tools that can often be quickly performed and easily recalled, especially in critical care areas.Specialized Scales/ScoringNormative Statementsno
Req-489Support interoperability between various systems2013 FormatThe system MAY be interoperable between the juvenile justice system, medical facilities, probation department, schools, and each state's human services agency.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-506Capture both presence and absence of conditions in history2013 FormatThe system SHALL provide the ability to capture patient history as both a presence and absence of conditions, i.e., the specification of the absence of a personal or family history of a specific diagnosis, procedure or health risk behavior.Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementsno
Req-507Import / export data with Surgeon General’s Family Health History Tool2013 Format
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7...
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7 v3 clinical genomics model with data mapping to the family history section of the HITSP C83 CCD content module for family history.
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Genetic information, Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-512Support communication with national, state, and local Child Protective Services, and more2013 FormatThe system MAY communicate with national, state, and local Child Protective Services, law enforcement, care physicians, prosecutor, medical examiner, Medicaid, and Insurance companies.Child Abuse ReportingNormative Statementsno
Req-513Retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the victim, teen pregnancy and births.2013 FormatIn cases of child abuse the system SHOULD provide the ability to retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the patient, teen pregnancy and births.Child Abuse Reporting, Well Child/Preventive CareNormative Statementsno
Req-515Ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance.Child Abuse Reporting, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-517Ability to access family history, including all parents2013 FormatThe system SHALL provide the ability to access family history, including all parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers; with contact information for each.Child Abuse ReportingNormative Statementsno
Req-518Ability to retrieve, capture, store, and display information regarding forensic evaluations2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display information regarding forensic evaluations.Child Abuse ReportingNormative Statementsno
Req-519Ability to access, store, and retrieve the date, time, and place of the occurrence2013 FormatThe system SHALL provide the ability to access, store, and retrieve the date, time, and place of the occurrence of alleged abuse.Child Abuse ReportingNormative Statementsno
Req-520Ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings2013 FormatThe system SHALL provide the ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings (both sexual and physical documentation of laboratory studies, and radiographic studies.Child Abuse ReportingNormative Statementsno
Req-522Ability to retrieve, capture, store, and display service plans, progress summaries, and assessments2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display service plans, progress summaries, and assessments.Child Abuse ReportingNormative 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-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-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-544Ability to comply with registry sharing/linking regulations and standards2013 FormatThe system SHALL comply with registry sharing/linking regulations and standards (HIPAA, HITECH, CHIPRA, etc.Registry LinkagesNormative Statementsno
Req-545Ability to comply with industry standards for interfaces and services2013 FormatThe system SHALL comply with industry standards for interfaces and services within the limitations of currently accepted standardsRegistry LinkagesNormative Statementsno
Req-546Support ability to export data for non-interfaced registries2013 FormatThe system SHALL provide user controlled export features such as protected text or data files for registries that can't or won't accept interfaced or service fed data.Registry LinkagesNormative Statementsno
Req-547Support the tracking of the release of information to outside registries through linkage mechanisms2013 Format
The system SHALL provide data elements that support the tracking of the release of information to outside registries through linkage mechanisms. Release tracking must cascade to the patient level (X patient's data linked to Y...
The system SHALL provide data elements that support the tracking of the release of information to outside registries through linkage mechanisms. Release tracking must cascade to the patient level (X patient's data linked to Y registry. Data elements: Releasing System, Receiving System, Date and Time of Release, Releasing Agent, Reason for Release, Trust Relationship, Release Mechanism.
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Registry LinkagesNormative 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-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-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-553Assign parts of the EHR to another patient identifier2013 FormatThe system SHOULD provide the ability to assign parts of the electronic health record to another patient identifier and delete them permanently from the former according to organizational policy or jurisdictional law relating to protections of birth records of adoptees.Patient Identifier, Security and ConfidentialityNormative Statementsno
Req-556Document authority for consent on behalf of minors2013 FormatThe system SHALL allow for documentation of authority of foster parents or custodians to give consent on behalf of a minor patient, including unlimited number of different foster parents or custodians.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-557Document time restrictions on authority for consent on behalf of patient2013 FormatThe system SHALL provide the ability to document any time restrictions on the patient's guardian, foster parent or custodian's level of authority to make decisions on behalf of the patient.Parents and Guardians and Family Relationship Data, Security 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-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-561Patient Knowledge Access2013 Format
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable...
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable information to research a health question, follow up from a clinical visit, identify treatment options, or other health information needs. The information may be linked directly from entries in the health record, or may be accessed through other means such as key word search. The information may be provided as part of the EHR system but may also include patient information from external databases or specific websites.
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Well Child/Preventive CareFunctionno
Req-562Support for Knowledge Access2013 FormatSystem supports Knowledge Access.Well Child/Preventive CareHeaderno
Req-563Clinical Task Assignment and Routing2013 Format
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom...
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom the task can be assigned will be determined by the specific needs of practitioners in a care setting. Task-assignment lists help users prioritize and complete assigned tasks. For example, after receiving communication (e.g. a phone call or e-mail from a patient, the triage nurse routes or assigns a task to return the patient's call to the physician who is on call. Task creation and assignment may be automated, where appropriate. An example of a system-triggered task is when lab results are received electronically; a task to review the result is automatically generated and assigned to a clinician. Task assignment ensures that all tasks are disposed of by the appropriate person or role and allows efficient interaction of entities in the care process.
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Well Child/Preventive CareFunctionno
Req-564Support for Referral Process2013 Format
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof...
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof are presented to the provider. Standardized or evidence based protocols for appropriate workup prior to referral may be presented.
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Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-565Orders, Referrals, Results and Care Management2013 FormatSystem supports Orders, Referrals, Results and Care Management.Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareHeaderno
Req-566Performance and Accountability Measures2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. These reports may include measures related to process, outcomes, costs of care, may be used in 'pay for performance' monitoring and adherence to best practice guidelines. The system needs to provide the report generating capability to easily create these reports or provide for the export of data to external report generating software.
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Quality MeasuresFunctionno
Req-568Manage Referrals2013 Format
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking...
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking of a referral from one care provider to another is supported, whether the referred to or referring providers are internal or external to the healthcare organization. Guidelines for whether a particular referral for a particular patient is appropriate in a clinical context and with regard to administrative factors such as insurance may be provided to the care provider at the time the referral is created.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-569Support for Non-Medication Ordering2013 Format
STATEMENT: Display and request provider validation of information necessary for non-medication orders that make the order pertinent, relevant and resource-conservative at the time of provider order entry.

DESCRIPTION: Possible order entry support includes, but...
STATEMENT: Display and request provider validation of information necessary for non-medication orders that make the order pertinent, relevant and resource-conservative at the time of provider order entry.

DESCRIPTION: Possible order entry support includes, but is not limited to: notification of missing results required for the order, suggested corollary orders, notification of duplicate orders, institution-specific order guidelines, guideline-based orders/order sets, order sets, order reference text, patient diagnosis specific recommendations pertaining to the order. Also, warnings for orders that may be inappropriate or contraindicated for specific patients (e.g. X-rays for pregnant women are presented.

Non-medication orders include orders such as:
• supplies such as 4x4's and ACE bandages
• non-medical devices such as TTY phones for the hearing impaired
• groups of supplies or kits common to an organization
• simple durable medical equipment (DME such as crutches or walkers
• complex DME such as wheelchairs and hospital beds
• therapies and other services that may require a referral and/or an authorization for insurance coverage
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-570Support for Inter-Provider Communication2013 Format
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or...
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or jurisdictional law.
DESCRIPTION: Communication among providers involved in the care process can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room to asynchronous communication (for example, consult reports between physicians Some forms of inter-practitioner communication will be paper based and the EHR-S must be able to produce appropriate documents.
The system should provide for both verbal and written communication. These exchanges would include but not limited to consults, and referrals as well as possible exchanges within the office as part of the provision and administration of patient care (for example, the communication of new information obtained within the office environment during the process of administration of a tetanus shot while the patient is in the exam room
The system should support the creation and acceptance of paper artifacts where appropriate.
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Child Welfare, Primary Care ManagementFunctionno
Req-571Outcome Measures and Analysis2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. The system needs to provide the report generating capability to easily create these reports or provide for the export of data to external report generating software. The system may also provide the functionality to prompt for the collection of necessary information at the appropriate time in a patient encounter if such collection need can be properly defined in a supportive workflow.
e.g. Requesting specific information for reporting of emergency services such as gun shot, suspected abuse, communicable diseases etc., or for the collection of additional research data for specific a specific diagnosis.
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Well Child/Preventive CareFunctionno
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
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-575Non-Medication Orders and Referrals Management2013 FormatManage Non-Medication Orders and ReferralsMedication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-576Clinical Workflow Tasking2013 Format
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment....
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment. Functions must exist in the EHR-S that support electronically any workflow that previously depended on the existence of a physical artifact (such as the paper chart, a phone message slip in a paper based system. Tasks differ from other more generic communication among participants in the care process because they are a call to action and target completion of a specific workflow in the context of a patient's health record (including a specific component of the record Tasks also require disposition (final resolution The initiator may optionally require a response. For example, in a paper based system, physically placing charts in piles for review creates a physical queue of tasks related to those charts. This queue of tasks (for example, a set of patient phone calls to be returned must be supported electronically so that the list (of patients to be called is visible to the appropriate user or role for disposition. Tasks are time-limited (or finite The state transition (e.g. created, performed and resolved may be managed by the user explicitly or automatically based on rules. For example, if a user has a task to signoff on a test result, that task should automatically be marked complete by the EHR when the test result linked to the task is signed in the system. Patients will become more involved in the care process by receiving tasks related to their care. Examples of patient related tasks include acknowledgement of receipt of a test result forwarded from the provider, or a request to schedule an appointment for a pap smear (based on age and frequency criteria generated automatically by the EHR-S on behalf of the provider.
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Well Child/Preventive CareHeaderno
Req-577Measurement, Monitoring, and Analysis2013 FormatSTATEMENT: Support measurement and monitoring of care for relevant purposesChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-578Locate records based on previous names2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-579Report demographic data2013 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.
Birth Information, Child WelfareNormative Statementsno
Req-580Historical demographic data2013 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.
Child WelfareNormative Statementsno
Req-582Indicate unknown patient gender2013 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.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-583Compute post conceptional age2013 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.
Birth Information, Growth Data, Prenatal ScreeningNormative Statementsno
Req-584Amend administrative or financial data2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-586Create custom clinical summaries2013 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-587Access custom clinical summaries2013 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-590Document assent for patients unable to consent2013 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.
Security and ConfidentialityNormative Statementsno
Req-593Source of allergy data2013 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.
Well Child/Preventive CareNormative Statementsno
Req-594Allergy occurrence date2013 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.
Well Child/Preventive CareNormative Statementsno
Req-595Report adverse events2013 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.
Immunizations, Registry LinkagesNormative Statementsno
Req-597Capture medication dates2013 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.
Medication ManagementNormative Statementsno
Req-598Display inactive problems2013 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.
Well Child/Preventive CareNormative Statementsno
Req-599Discrete immunization data2013 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.
ImmunizationsNormative Statementsyes
Req-600Report immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsno
Req-601Immunization consent status2013 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.
ImmunizationsNormative Statementsno
Req-602Document using standard assessments2013 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.
Children with Special Healthcare NeedsNormative Statementsno
Req-607Order blood products in pediatric units2013 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.
Medication ManagementNormative Statementsno
Req-608Immunizations based on risk factors2013 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.
ImmunizationsNormative Statementsno
Req-609Data pertinent to immunization administration2013 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.
ImmunizationsNormative Statementsno
Req-610Reporting immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsyes
Req-611Synchronize immunization histories with registry2013 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.
Immunizations, Registry LinkagesNormative Statementsyes
Req-612Update immunization schedule on demand2013 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.
ImmunizationsNormative 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-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-619BMI and growth velocity2013 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.
Growth DataNormative Statementsno
Req-622Growth chart data2013 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.
Growth DataNormative Statementsno
Req-624Mid-parental height2013 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.
Growth DataNormative Statementsno
Req-626Bone age2013 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.
Growth DataNormative Statementsno
Req-627User Interface preferences2013 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.
Growth Data, Specialized Scales/ScoringNormative Statementsno
Req-628Height input2013 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.
Growth DataNormative Statementsno
Req-629Normal data range per Tanner stage2013 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.
Growth DataNormative Statementsno
Req-630Print growth chart2013 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.
Growth DataNormative Statementsno
Req-631Templates to facilitate documentation2013 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-633Patient-milk product matching2013 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.
Well Child/Preventive CareNormative Statementsno
Req-634Breast milk aliquot data2013 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.
Well Child/Preventive CareNormative Statementsno
Req-635Define formal health records2013 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.
Well Child/Preventive CareNormative Statementsno
Req-636Compare patient assessments to best practices2013 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.
Well Child/Preventive CareNormative Statementsno
Req-637Site-specific care plans and guidelines2013 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.
Well Child/Preventive CareNormative Statementsno
Req-638Create site-specific care plans and guidelines from standard ones2013 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.
Well Child/Preventive CareNormative Statementsno
Req-639Access to age-specific guidelines2013 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.
EPSDT, Well Child/Preventive CareNormative Statementsyes
Req-640Capture continuum of care processes2013 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-641Display continuum of care processes2013 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-642Choice of action based on care plan2013 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-643Use demographic-specific norms to manage care2013 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-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-646Compute weight-based drug dosage2013 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.
Medication ManagementNormative Statementsno
Req-648Alternative dosing weight2013 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.
Medication ManagementNormative Statementsyes
Req-649Combination drug dosage functions2013 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.
Medication ManagementNormative Statementsno
Req-655Indicate formulae for drug dose recommendations2013 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.
Medication ManagementNormative Statementsno
Req-657Record vaccine refusal reasons2013 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.
ImmunizationsNormative Statementsno
Req-658Data elements for pediatric ordering2013 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-659Alert based on age-specific norms2013 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 Statementsyes
Req-660Support for age-appropriate referrals2013 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-662Multilingual educational material2013 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-663Document recipient of educational material2013 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-664Identify recipient-appropriate educational material2013 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-665Mask selected EHR data2013 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.
Security and ConfidentialityNormative Statementsyes
Req-666Audit trails2013 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.
Growth DataNormative 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-668Automate data retrieval2013 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.
Registry LinkagesNormative Statementsno
Req-669Sibling data sharing2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-670Custom patient record reports2013 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.
Well Child/Preventive CareNormative Statementsno
Req-671Define formal health record2013 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.
Security and ConfidentialityNormative Statementsno
Req-672Flexible record element order in reports2013 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.
Well Child/Preventive CareNormative Statementsno
Req-673Report summaries: hard copy and electronic2013 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.
Immunizations, Registry LinkagesNormative Statementsno
Req-674Patient indicators on reports2013 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.
Patient IdentifierNormative Statementsno
Req-675Customize reports to mandated formats2013 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.
Well Child/Preventive CareNormative Statementsno
Req-676Generate structured clinical and administrative reports2013 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.
Activity Clearance, Well Child/Preventive CareNormative Statementsno
Req-677Service reports2013 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.
Registry LinkagesNormative Statementsyes
Req-679Identify and Maintain a Patient Record2013 Format
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and...
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and linked to the patient record. Static data elements as well as data elements that will change over time are maintained. The patient is uniquely identified, after which the record is tied to that patient. Combining information on the same patient, or separating information where it was inadvertently captured for the wrong patient, helps maintain health information for a single patient. In the process of creating a patient record, it is at times advantageous to replicate identical information across multiple records, so that such data does not have to be re-entered. For example, when a parent registers children as new patients, the address, guarantor, and insurance data may be propagated in the children's records without having to re-enter them.
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Parents and Guardians and Family Relationship DataFunctionno
Req-680Manage Orders for Blood Products and Other Biologics2013 Format
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics...
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics including discontinuance orders. Use of such products in the provision of care is captured. Blood bank or other functionality that may come under jurisdictional law or other regulation (e.g. by the FDA in the United States is not required; functional communication with such a system is required.
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Medication ManagementFunctionno
Req-682Support for Result Interpretation2013 Format
STATEMENT: Evaluate results and notify provider of results within the context of the patient's healthcare data.
DESCRIPTION: Possible result interpretations include, but are not limited to: abnormal result evaluation/notification, trending of results (such as discrete...
STATEMENT: Evaluate results and notify provider of results within the context of the patient's healthcare data.
DESCRIPTION: Possible result interpretations include, but are not limited to: abnormal result evaluation/notification, trending of results (such as discrete lab values evaluation of pertinent results at the time of provider order entry (such as evaluation of lab results at the time of ordering a radiology exam evaluation of incoming results against active medication orders.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-683Healthcare Resource Availability2013 Format
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In...
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In times of identified local or national emergencies and upon request from authorized bodies, provide current status of healthcare resources including, but not limited to, available beds, providers, support personnel, ancillary care areas and devices, operating theaters, medical supplies, vaccines, and pharmaceuticals. The intent is to enable the authorized body to distribute or re-distribute either resources or patient load to maximize efficient healthcare delivery. In addition, these functions may also be used for internal assessment and planning purposes by facility administrators
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Parents and Guardians and Family Relationship DataFunctionno
Req-684Propagate identical data for related patients2013 FormatIF related patients register with any identical data, THEN the system SHOULD provide the ability to propagate that data to all their records.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-685Date of allergy documentation2013 FormatThe system SHALL provide the ability to capture and display the date on which allergy information was entered.Medication Management, Well Child/Preventive CareNormative Statementsno
Req-686Medication administration details2013 FormatThe system SHALL provide the ability to capture all pertinent details of the medication administration including medication name, strength, dose, route, time of administration, exceptions to administration, and administrator of the medication.Medication ManagementNormative Statementsno
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-690Recommend required immunizations per schedules2013 FormatThe system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.EPSDT, ImmunizationsNormative Statementsno
Req-693Support for Notification and Response2013 Format
STATEMENT: Upon notification by an external, authoritative source of a health risk within the cared for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.
DESCRIPTION: After receiving a...
STATEMENT: Upon notification by an external, authoritative source of a health risk within the cared for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.
DESCRIPTION: After receiving a notice of a health risk within a cared-for population from public health authorities or other external authoritative sources:
1. Identify and notify individual care providers or care managers that a risk has been identified and requires attention; and
2. Provide suggestions on the appropriate course of action.
A care provider now has the ability to decide how patients are notified, if necessary.
For example, this function may be used after detection of a local outbreak of hepatitis A, advising providers of the at-risk population and potential prophylactic treatment.
A second example might be the dissemination of new care guidelines for elderly patients with a specific chronic disease.
Notifications to clinicians or patients may occur by telephone, email, FAX or other methods
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Well Child/Preventive CareFunctionno
Req-694Registry and Directory Services2013 Format
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and...
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and employers for administrative and financial purposes;
- public health agencies for healthcare purposes, and
- healthcare resources and devices for resource management purposes.
DESCRIPTION: Registry and directory service functions are critical to successfully managing the security, interoperability, and the consistency of the health record data across an EHR-S. These services enable the linking of relevant information across multiple information sources within, or external to, an EHR-S for use within an application.
Directories and registries support communication between EHR Systems and may be organized hierarchically or in a federated fashion. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider's EHR-S interrogates a local, regional, or national registry to find the patient's previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules.
An example of local registry usage is an EHR-S application sending a query message to the Hospital Information System to retrieve a patient's demographic data.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
Req-696Manage Order Sets2013 Format
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease...
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease state according to standards or other criteria. Recommended order sets may be presented based on patient data or other contexts.
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Well Child/Preventive CareFunctionno
Req-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
Req-698Manage Non-Medication Patient Care Orders2013 Format
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and...
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and discontinue orders. Examples include orders to transfer a patient between units, to ambulate a patient, for medical supplies, durable medical equipment, home IV, and diet or therapy orders.
Each item ordered includes the appropriate detail, such as order identification and instructions. Orders should be communicated to the correct service provider for completion.
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Medication ManagementFunctionno
Req-701Encounter Specific Functionality2013 Format
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining...
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining and supporting the appropriate data collection, import, export, extraction, linkages and transformation. As an example, a pediatrician is presented with diagnostic and procedure codes specific to pediatrics. Business rules enable automatic collection of necessary data from the patient's health record and patient registry. As the provider enters data, workflow processes are triggered to populate appropriate transactions and documents. For example, data entry might populate an eligibility verification transaction or query the immunization registry.
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Specialized Scales/ScoringFunctionno
Req-702Secure Data Routing2013 Format
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the...
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the entities (applications, institutions, directories it expects. This function depends on entity authorization and authentication to be available in the system. For example, a physician practice management application in an EHR-S might send claim attachment information to an external entity. To accomplish this, the application must use a secure routing method, which ensures that both the sender and receiving sides are authorized to engage in the information exchange. Known sources and destinations can be established in a static setup or they can be dynamically determined. Examples of a static setup are recordings of IP addresses or recordings of DNS names. For dynamic determination of known sources and destinations systems can use authentication mechanisms as described in Req-759 (HL7 ID: IN.1.1 For example, the sending of a lab order from the EHRS to a lab system within the same organization usually uses a simple static setup for routing. In contrast sending a lab order to a reference lab outside of the organization will involve some kind of authentication process.
In general, when the underlying network infrastructure is secure (e.g. secure LAN or VPN the simple static setup is used.
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Parents and Guardians and Family Relationship DataFunctionno
Req-703Support for Medication Recommendations2013 Format
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice...
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice standards (e.g. cost or adherence to guidelines a generic brand, a different dosage, a different drug, or no drug (watchful waiting Suggest lab order monitoring as indicated by the medication or the medical condition to be affected by the medication. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etc.
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Medication ManagementFunctionno
Req-715Standard Terminologies and Terminology Models2013 Format
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a...
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc. Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
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Medication Management, Special Terminology and InformationFunctionno
Req-718Entity Access Control2013 Format
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of...
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of an EHR-S. To ensure that access is controlled, an EHR-S must perform authentication and authorization of users or applications for any operation that requires it and enforce the system and information access rules that have been defined.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
Req-719Interchange Agreements2013 Format
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION:...
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION: Systems that wish to communicate with each other, must agree on the parameters associated with that information exchange. Interchange Agreements allow an EHR-S to describe those parameters/criteria.
An EHR-S can use the entity registries to determine the security, addressing, and reliability requirements between partners.
An EHR-S can use this information to define how data will be exchanged between the sender and the receiver.
Discovery of interchange services and capabilities can be automatic.
For example:
- A new application can automatically determine a patient demographics source using a Universal Description and Discovery Integration (UDDI for source discovery, and retrieve the Web Services Description Language (WSDL specification for binding details.
- Good Health Hospital is a member of AnyCounty LabNet, for sharing laboratory results with other partners. Good Health Hospital periodically queries LabNet's directory (UDDI to determine if additional information providers have joined LabNet. When new information providers are discovered, the Good Health IT establishes the appropriate service connections based upon the Service Description (WSDL
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ImmunizationsFunctionno
Req-720Support unit conversion during data entry and display2013 FormatThe system SHALL provide unit conversions calculation and display during data entry and data display (e.g. lbs/kgGrowth DataNormative Statementsno
Req-721Patient Reminder Information Updates2013 Format
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health...
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health organizations, etc. may periodically send updates to patient care providers. The system should be capable of generating patient reminders based on the recommendations of these organizations. Patient reminders could be provided to patients by a number of means including phone calls, or mail. A record of such reminders may become part of a patient's record. Examples of reminders could include a recommended immunization, prophylactic guidelines for MVP, patient self-testing for disease, etc.
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Well Child/Preventive CareFunctionno
Req-722Supportive Function Maintenance2013 FormatSTATEMENT: Update EHR supportive content using a manual or automated process.Well Child/Preventive CareHeaderno
Req-723Ability to incorporate risk factors and/or anticipatory guidance2013 FormatThe system MAY incorporate risk factors and/or anticipatory guidance relevant to body composition, age, and gender into display/printout of growth charts.Growth DataNormative Statementsno
Req-724Support for population, maintenance, and export of registries2013 FormatThe system SHOULD support the population, maintenance, and export of registries including patients with significant anthropometric findings and related disease risk factors.Growth DataNormative Statementsno
Req-725Support for population level reporting2013 FormatThe system SHOULD support population level reporting of collected and derived measures of growth and body composition and related clinical and demographic information.Growth DataNormative Statementsno
Req-730Flag special healthcare needs2013 FormatThe system SHALL support the flagging of individuals with special healthcare needs or complex conditions, to facilitate care management, decision support, and reporting.Children with Special Healthcare NeedsNormative Statementsno
Req-732Ability to search service registries2013 FormatService registry entries SHOULD be searchable by name, location, service categories provided, and/or parent organization.Children with Special Healthcare NeedsNormative Statementsno
Req-739Support for Monitoring Response Notifications Regarding a Specific Patient’s Health2013 Format
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that...
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that expected follow-up for a specific patient event (e.g., follow up to error alerts or absence of an expected lab result has not occurred and communicate the omission to appropriate care providers in the chain of authority. The notification process requires a security infrastructure that provides the ability to match a care provider's clinical privileges with the clinical requirements of the notification.
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Children with Special Healthcare NeedsFunctionno
Req-740Manage Medication Orders2013 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.
Medication ManagementFunctionno
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-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
Req-765Store and Manage Health Record Information2013 Format
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified...
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified data.

General examples of unstructured health record information include:
- text
- word processing document
- image
- multimedia

Specific examples include:
- text message to physician
- patient photo
- letter from family
- scanned image of insurance card
- dictated report (voice recording

Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHR-S (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.

Managing healthcare data includes capture, retrieval, deletion, correction, amendment, and augmentation. Augmentation refers to providing additional information regarding the healthcare data, which is not part of the data itself, e.g. linking patient consents or authorizations to the healthcare data of the patient.
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Well Child/Preventive CareHeaderno
Req-767Manage Structured Health Record Information2013 Format
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
-...
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHRS (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.
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Well Child/Preventive CareFunctionno
Req-772Interchange Standards Versioning and Maintenance2013 Format
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its...
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its natural update process.

DESCRIPTION:
The life cycle of any given standard results in changes to its requirements. It is critical that an organization know the version of any given standard it uses and what its requirements and capabilities are.

For example, if the organization migrates to an HL7 v2.5 messaging standard, it may choose to take advantage of new capabilities such as specimen or blood bank information. The organization may find that certain fields have been retained for backwards compatibility only or withdrawn altogether. The EHR-S needs to be able to handle all of these possibilities.

Standards typically evolve in such a way as to protect backwards compatibility. On the other hand, sometimes there is little, or no, backwards compatibility when an organization may need to replace an entire standard with a new methodology. An example of this is migrating from HL7 v2 to HL7 v3.

Interchange standards that are backward compatible support exchange among senders and receivers who are using different versions. Version control ensures that those sending information in a later version of a standard consider the difference in information content that can be interchanged effectively with receivers, who are capable of processing only earlier versions. That is, senders need to be aware of the information that receivers are unable to capture and adjust their business processes accordingly.
Version control enables multiple versions of the same interchange standard to exist and be distinctly recognized over time.
Since interchange standards are usually periodically updated, concurrent use of different versions may be required.
Large (and/or federated organizations typically need to use different versions of an interchange standard to meet internal organizational interoperability requirements.
For example, the enterprise-wide standard might use HL7 v2.5 for Lab messages, but some regions of the enterprise might be at a lower level.
It should be possible to retire deprecated interchange standards versions when applicable business cycles are completed while maintaining obsolete versions. An example use of this is for possible claims adjustment throughout the claim's life cycle.
When interchange standards change over time, it is important that retrospective analysis and research correlate and note gaps between the different versions' information structures to support the permanence of concepts over time. An example use of this is the calculation of outcome or performance measures from persisted data stores where one version of a relevant interchange standard, e.g., CDA Release 1 captures the relevant data, e.g., discharge data, differently than CDA Release 2.
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Immunizations, Registry LinkagesFunctionno
Req-781Information View2013 Format
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For...
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For example, a nursing supervisor may elect or prefer to see summary data on all patients as the default view.
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Immunizations, Well Child/Preventive CareFunctionno
Req-798Referral completion capture2013 FormatThe system SHOULD provide the ability to capture completion of a referral appointment.Primary Care ManagementNormative Statementsno
Req-800Newborn dried blood spot collection time and state2013 Format
The system SHALL record the state and collection date and time with precision no less than the nearest clock hour for when each newborn screening dried blood spot was collected. Multiple samples at multiple times...
The system SHALL record the state and collection date and time with precision no less than the nearest clock hour for when each newborn screening dried blood spot was collected. Multiple samples at multiple times may be collected, such as in those states that require repeat testing or on prematurely born neonates.
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Newborn ScreeningNormative Statementsno
Req-801Record time when mandated point-of-service testing occurred2013 Format
The system SHALL record the date and time with precision no less than the nearest clock hour when a mandated non-blood spot newborn screening occurred, as well as the specific modality and the results of...
The system SHALL record the date and time with precision no less than the nearest clock hour when a mandated non-blood spot newborn screening occurred, as well as the specific modality and the results of the screen using standard codified terms (e.g., SNOMED-CT Presently, this is only newborn hearing screening. Multiple screenings at multiple times may occur.
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Newborn ScreeningNormative Statementsno
Req-802Record refusal of newborn dried blood spot testing2013 FormatThe system SHALL capture refusal of newborn dried blood spot if such screening is refused by the child's legal guardian.Newborn ScreeningNormative Statementsno
Req-803Record refusal of point-of-service testing2013 FormatThe system SHALL capture refusal of non-blood spot newborn screening (e.g., newborn hearing screening if such screening is refused by the child's legal guardian.Newborn ScreeningNormative Statementsno
Req-809Report results of non-blood spot newborn screening tests2013 FormatThe system SHALL be able to report results of non-blood spot newborn screening tests to the state public health department according to their guidelines.Newborn ScreeningNormative Statementsno
Req-810Provide ACT sheets to clinicians after out-of-range newborn screening result2013 FormatThe system SHOULD provide guidance to clinicians about the management of an out-of-range newborn screening result by providing the HRSA-funded ACT sheets.Newborn ScreeningNormative Statementsno
Req-811Record final diagnosis for abnormal newborn screening results2013 FormatThe system SHALL record the final diagnosis for those with out-of-range or insufficient newborn screening results. This includes 'Normal' or the particular diagnosis.Newborn ScreeningNormative Statementsno
Req-812Record reporting of newborn screening results to the state health department2013 FormatThe system SHALL record that the diagnosis for those with an out-of-range or insufficient newborn screening result was provided to the state public health department according to their guidelines.Newborn ScreeningNormative Statementsno
Req-813Record parental notification of newborn screening diagnosis2013 FormatThe system SHALL record that the child's legal guardians were notified of any newborn screening-related diagnosis.Newborn ScreeningNormative Statementsno
Req-814Provide educational material from health department for newborn screening conditions2013 FormatThe system SHOULD provide parent educational material available from the state public health department regarding the appropriate newborn screening-related condition.Newborn ScreeningNormative Statementsno
Req-815Record diagnoses on patient problem summary list2013 FormatThe system SHOULD include all diagnoses resulting from newborn screening other than 'Normal' on a patient problem summary list.Newborn ScreeningNormative Statementsno
Req-818Support appropriate newborn screening and follow-up2013 FormatThe system SHALL incorporate the algorithms described in http://pediatrics.aappublications.org/content/121/1/192.abstract Exit Disclaimer to assure screening has been accomplished and that results have been followed up.Newborn ScreeningNormative Statementsno
Req-819Document appropriate newborn screening2013 FormatThe system SHALL document completion of the steps described in http://pediatrics.aappublications.org/content/121/1/192.abstract. Exit DisclaimerNewborn ScreeningNormative Statementsno
Req-822Newborn Screening Follow-Up2013 Format
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried...
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried blood spot analysis by state public health departments. More recently, point-of-service testing in the nursery (e.g., newborn hearing screening has been included. Another point-of-service test that will likely be added in the coming year to newborn screening is pulse oximetry to detect critical cyanotic congenital heart disease. Newborn screening is expanding at a rapid rate. Although the US Secretary of Health and Human Services makes recommendations about what should be included as part of newborn screening, individual states are responsible for developing their own panel, including the threshold for a positive test. Some states require retesting of all newborns. States have varying methods of short and long-term follow-up for those that have tested positive. Some parents may choose to have supplemental newborn screening through private laboratories. This is outside of the scope of this requirement statement.

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf. The U.S. National Library of Medicine (NLM has published the Newborn Screening Coding and Terminology to promote and facilitate the use of electronic health data standards for the conditions recommended for screening by the HHS Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC This is available at: http://newbornscreeningcodes.nlm.nih.gov/.

The National Newborn Screening and Genetics Resource Center (http://genes-r-us.uthscsa.edu/ provides continuously updated information on the conditions screened for in each state. In addition, links are available to each state program. The Resource Center also provides educational material for clinicians and family members.
Well-described clinical algorithms have been developed to guide general pediatricians and subspecialists in the process of newborn screening. These are available at: http://pediatrics.aappublications.org/content/121/1/192.abstract. Exit Disclaimer The requirements were designed to support these algorithms. In addition, these requirements support the transition from diagnosis through screening to chronic condition management and long-term follow-up as described in Kemper AR, Boyle CA, Aceves J, et al. Long-term follow-up after diagnosis resulting from newborn screening: statement of the US Secretary of Health and Human Services' Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Genet Med. 2008:10:259-261.
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Newborn ScreeningHeaderno
Req-823Newborn Screening Decision Support2013 Format

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf [1]. The U.S. National...

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf [1]. The U.S. National Library of Medicine (NLM has published the Newborn Screening Coding and Terminology to promote and facilitate the use of electronic health data standards for the conditions recommended for screening by the HHS Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC This is available at: http://newbornscreeningcodes.nlm.nih.gov/ [2].

The National Newborn Screening and Genetics Resource Center (http://genes-r-us.uthscsa.edu/ [3] provides continuously updated information on the conditions screened for in each state. In addition, links are available to each state program. The Resource Center also provides educational materials for clinicians and family members.
Well-described clinical algorithms have been developed to guide general pediatricians and subspecialists in the process of newborn screening. These are available at: http://pediatrics.aappublications.org/content/121/1/192.abstract[4]. Exit Disclaimer The requirements were designed to support these algorithms. In addition, these requirements support the transition from diagnosis through screening to chronic condition management and long-term follow-up as described in Kemper AR, Boyle CA, Aceves J, et al. Long-term follow-up after diagnosis resulting from newborn screening: statement of the US Secretary of Health and Human Services' Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Genet Med. 2008:10:259-261

Links:
------
[1] http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf
[2] http://newbornscreeningcodes.nlm.nih.gov/
[3] http://genes-r-us.uthscsa.edu/ Exit Disclaimer
[4] http://pediatrics.aappublications.org/content/121/1/192.abstract Exit Disclaimer
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Newborn ScreeningHeaderno
Req-824Age Precision2013 FormatBecause children change substantially during the first several years of life, their age must be calculated more precisely (during that period than that of adults, often with units considerably smaller than years.Well Child/Preventive CareFunctionno
Req-825Calculate patient age precisely enough to support environment-specific activities2013 FormatThe system SHALL calculate patient age precisely enough to support environment-specific activities that vary significantly in the first hours, days, and months of life.Well Child/Preventive CareNormative Statementsno
Req-826Calculate patient age to the minute2013 FormatThe system SHOULD calculate patient age no less precisely than the nearest minute for at least the first week of lifeWell Child/Preventive CareNormative Statementsno
Req-827Age Presentation2013 FormatAge PresentationWell Child/Preventive CareHeaderno
Req-828Age Unit Selection2013 FormatAge units must be appropriate to the actual age, required precision, social conventions, and the environment of care.Well Child/Preventive CareFunctionno
Req-829Present patient age using appropriate units2013 FormatThe system SHALL present patient age using units appropriate to the actual age of the patient, using appropriate thresholds for unit selectionWell Child/Preventive CareNormative Statementsno
Req-830Age unit threshold implementation rules2013 FormatThe system SHOULD develop age unit threshold implementation rules that account for the variable lengths of months.Well Child/Preventive CareNormative Statementsno
Req-831Ability to customize age unit thresholds2013 FormatThe system SHOULD enable implementation-specific customization of the age unit thresholds.Well Child/Preventive CareNormative Statementsno
Req-832Patient age in units appropriate to environment of care2013 FormatThe system SHALL present patient age using units appropriate to the environment of care as well as the patient age.Well Child/Preventive CareNormative Statementsyes
Req-833Support adapting of age units per care environment and age threshold needs2013 FormatThe system SHALL enable age units to be adapted to care environment-specific age thresholds.Well Child/Preventive CareNormative Statementsno
Req-834Unit-specific calculation2013 FormatUnit-specific calculationWell Child/Preventive CareFunctionno
Req-835Implement age rounding rules2013 Format
The system SHOULD implement age rounding rules that conform to social conventions of age representation
- Age in years, months, weeks, and days should be incremented at the 'day' level of precision, and rounded down...
The system SHOULD implement age rounding rules that conform to social conventions of age representation
- Age in years, months, weeks, and days should be incremented at the 'day' level of precision, and rounded down to an integer
- Age in months should be calculated as though dates that do not exist in a particular month are equivalent to the 1st day of the following month.
- Age in hours and minutes should be incremented at the 'minute' level of precision, and rounded down to an integer
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Well Child/Preventive CareNormative Statementsno
Req-837Precise birth date and time entry2013 FormatThe system SHALL enable entry of the date and time of birth (no less precisely than to the minute if required by the scope of practice.Birth InformationNormative Statementsyes
Req-838Precise birth date and time storage2013 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.
Birth InformationNormative Statementsno
Req-839Display growth charts2013 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.
Growth DataNormative Statementsyes
Req-840Growth Charts2013 Format
Anthropometric measures and trends in growth are central to the prevision of pediatric care. Abnormal growth is often the first sign of underlying chronic illness. In addition, body size is necessary for the dosing of...
Anthropometric measures and trends in growth are central to the prevision of pediatric care. Abnormal growth is often the first sign of underlying chronic illness. In addition, body size is necessary for the dosing of most drugs in pediatrics. In general, there are three main direct measures - head circumference, length/height, and weight. Body mass index is calculated based on weight and height.
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Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-843Display date of each data point on growth chart2013 FormatFor all growth charts the curve SHOULD provide a display of the date of each data point shown on the curve.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-844Growth chart magnification2013 FormatFor all growth charts the system SHOULD allow the magnification ("zooming" of the display in order to facilitate understanding of curves where there are many densely-spaced data points.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-845Ability to exclude data points from growth charts2013 FormatFor all growth charts the system SHOULD allow for the exclusion of selected data points, as in when a patient presents with an acute abnormality that affects the measurement (e.g., acute dehydrationGrowth Data, Primary Care ManagementNormative Statementsno
Req-846Support display of normative curves in standard deviations2013 FormatFor all curves described here, the system MAY provide views of normative curves in standard deviations to allow for the interpretation of more extreme measurements (e.g., charts for very obese children where all measurements are >95th percentileGrowth DataNormative Statementsno
Req-847Head Circumference2013 FormatHead circumference is typically measured in newborns and then at every well-child visit through 36 months of life. Head circumference may also be measured at other times based on clinician concern, or in cases of chronic neurologic disease or developmental delayChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-848Record head circumference precisely2013 FormatThe system SHALL record head circumference at least to the half centimeter, or quarter inch, based on user preference, and record the date of measure.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-850Display head circumference on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-851Length/Height2013 FormatLength is typically measured in newborns and then at every well-child visit through 36 months of life. Afterwards, height is typically recorded. Length/height may also be measured at other times based on clinician concern.Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-852Measure length/height precisely2013 FormatThe system SHALL record length/height at least to the half centimeter, or quarter inch, based on user preference, whether the measure was length or height, and record the date of measure.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-853Display length/height data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded length/height data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-854Display length/height data on population-specific growth charts2013 FormatThe system MAY display length/height data on selected population-specific growth charts (e.g., children with Down syndrome or a particular ethnicityGrowth DataNormative Statementsno
Req-855Weight2013 FormatWeight is typically measured in newborns and then at every patient encounter.Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-856Weight precision: 2 months and younger2013 FormatThe system SHALL record weight in kilograms with up to 3 decimal points (i.e., in grams through 2 months of life or 10 kg, whichever comes later.Growth DataNormative Statementsno
Req-857Weight precision: 2 months and older2013 FormatThe system SHALL record weight in kilograms with up to two decimal points in children after 2 months of life or 10 kg, whichever comes later.Growth DataNormative Statementsno
Req-858Support precise measurement units in both metric and English system2013 FormatThe system SHALL have similar levels of precision in both the Metric and English systems for recording weight.Growth DataNormative Statementsno
Req-859Display weight data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded weight data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-860Display weight data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-861Record clothes/diaper status when weighed2013 FormatThe system SHALL record whether clothes or diaper were on when weighed.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-862Ability to record tare weight for DME2013 FormatThe system SHALL allow recording of tare weight for durable medical equipment such as wheelchairs and walkers to facilitate easy weighing of children with special needs.Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-863Body Mass Index2013 FormatBody mass index (BMI is a calculated, based on weight and height. Currently, normative data exist only for children 2 and older. It is usually measured at all well-child visits, but can be assessed at other times based on clinician concern.Children with Special Healthcare Needs, Growth Data, Well Child/Preventive CareFunctionno
Req-864Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal place at every well-child visit beginning at 24 months of life.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-865Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal point at any age based on system query.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-866Display BMI data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display body mass index (BMI data on both the sex-specific CDC and WHO growth charts.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-867Display BMI data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-868Alert to obtain height when BMI required2013 FormatThe system MAY allow alerting to indicate the need to obtain a height when a BMI is required (by policy or guidelineGrowth DataNormative Statementsno
Req-869Height Velocity2013 FormatAssessment of a child's growth rate by height.Growth DataFunctionno
Req-870Display growth velocity data on normative growth chart2013 FormatThe system SHALL calculate growth velocity from height data, and plot it on normative curves provided by agencies such as CDC and WHO.Growth DataNormative Statementsno
Req-871Display bone age and growth velocity data together2013 FormatThe system SHOULD allow inclusion of bone age data on the same display as the growth velocity data.Growth DataNormative Statementsno
Req-872Anthropometric prescribing support2013 FormatMost pediatric drug dosing is weight-based. Sometimes drug dosing is based on body surface area or other anthropometric measures (e.g., oncology drugsGrowth DataHeaderno
Req-873Support exporting of anthropometric data2013 FormatThe system MAY export anthropometric data to the drug prescribing module to provide additional support.Growth DataNormative Statementsno
Req-874Predictive growth and clinical context2013 FormatPredictive growth and clinical contextGrowth DataHeaderno
Req-875Display predictive growth curves2013 FormatThe system MAY display predictive growth curves or growth targets based on mid-parental height or other techniques.Growth DataNormative Statementsno
Req-876Display clinical context for each point on growth chart2013 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.
Growth DataNormative Statementsno
Req-877Editing of Data2013 FormatData editing aspects of the system.Growth DataFunctionno
Req-878Correct growth data2013 FormatThe system SHALL have a process to correct growth data. This process shall include a method to track changes.Growth DataNormative Statementsno
Req-879Correct growth data directly from growth chart2013 FormatThe system SHOULD allow the user to correct growth data directly from the growth chart, by interacting directly with the graphical data point, rather than having to first go to a tabular (flowsheet representation.Growth DataNormative Statementsno
Req-881Document reasons for drug alert override2013 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.
Medication ManagementNormative Statementsno
Req-882Drug dosage computation2013 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.
Medication ManagementNormative Statementsyes
Req-883Future dose calculation factors2013 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.
Medication ManagementNormative Statementsno
Req-884Alert for invalid dose computation data2013 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.
Medication ManagementNormative Statementsno
Req-885Alert for unavailable pediatric dosing2013 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.
Medication ManagementNormative Statementsno
Req-886Liquid drug prescriptions2013 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.
Medication ManagementNormative Statementsno
Req-887Drug contraindications in specific child populations2013 FormatThe system SHOULD provide the ability to detect contraindications in specific child populations (e.g. age groups or those with liver issues for individual medications and any combined pharmacotherapy and inform the user during ordering.Medication ManagementNormative Statementsno
Req-888High risk drug combinations in children2013 FormatThe system SHALL provide the ability to detect high risk drug combination alerts specific to children and inform the user during ordering.Medication ManagementNormative Statementsyes
Req-890Indicate common side effects2013 FormatThe system MAY provide the ability to indicate common side effects, including those unique to or more common in children, and inform the user during ordering.Medication ManagementNormative Statementsno
Req-891Alternative administration techniques2013 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-892Child-appropriate doses in provider-specific medication lists2013 FormatThe system SHALL support child-appropriate dosing in provider specific medication lists ("favorites" including default route, dose, frequency, and quantity (e.g. accommodate weight-based doses such as <mg or mcg or gm>/kg/dose or <mg or mcg or gm>/kg/dayMedication ManagementNormative Statementsno
Req-893Documentation of compliance and refusal of care2013 FormatThe system MAY provide the ability to require documentation of information regarding patient compliance with prescribed treatment, including parent/guardian refusal of treatment.Medication ManagementNormative Statementsno
Req-894Require documentation of therapeutic labs2013 FormatThe system SHOULD provide the ability to require documentation of therapeutic labs or appropriate lab levels recommended for child dosing.Medication ManagementNormative Statementsno
Req-895Birth History2013 FormatBirth represents a significant milestone. Newborn babies undergo large physiologic changes that make them susceptible to medical problems in the perinatal period. An accurate birth history provides the foundation for good newborn and child health care.Birth Information, Patient Identifier, Specialized Scales/ScoringHeaderno
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
Req-897Birth weight in kg2013 FormatThe system SHALL record birth weight in kilograms to 3 decimal places.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-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-900Record singleton, twin, or multiple gestation2013 FormatThe system SHALL record whether the infant is a singleton, twin, or multiple gestation.Birth 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-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-903Symmetry2013 FormatThe system SHALL record symmetry at birth as Symmetrical or Asymmetrical.Birth InformationNormative Statementsno
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-908Maternal rubella status2013 FormatThe system SHALL record maternal rubella status as Immune, Non-Immune or Unknown.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-910Maternal hepatitis B status2013 FormatThe system SHALL record maternal hepatitis B 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-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-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-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-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-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-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-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-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-928Perinatal magnesium sulfate administration2013 FormatThe system SHALL record whether the mother received magnesium sulfate doses prior to or during delivery.Birth InformationNormative Statementsno
Req-929Record tocolytics administration2013 FormatThe system SHALL record whether mother received tocolytics and, if so, which one(sBirth 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-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-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth 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-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-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-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-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-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-9405 minute Apgar2013 FormatThe system SHALL record Apgar score at 5 minutes (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-94110 minute Apgar2013 FormatThe system SHALL record Apgar score at 10 minutes (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-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-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.Birth InformationNormative Statementsno
Req-944Oxygen saturation in delivery room2013 FormatThe system SHALL record percutaneous oxygen saturation measurements in the delivery room.Birth InformationNormative Statementsno
Req-945Clinical staff at delivery2013 FormatThe system SHALL record the pediatrician(s nurse(s and respiratory therapist(s present at delivery.Birth InformationNormative Statementsno
Req-947Neonatal physical exam2013 FormatThe system SHALL record the physical exam of the neonate.Birth InformationNormative Statementsno
Req-948Neonatal Resuscitation2013 FormatResuscitation is common in the delivery room and the steps taken must be documented as part of the record.Birth InformationFunctionno
Req-949Respiratory support in neonatal resuscitation2013 FormatThe system SHALL record respiratory support used during resuscitation (Blow-by O2, Nasal Cannula O2, Bag / Mask Ventilation, CPAP, or Endotracheal IntubationBirth InformationNormative Statementsno
Req-950FiO2 administration in neonatal resuscitation2013 FormatThe system SHALL record the FiO2 delivered to the infant during resuscitation.Birth InformationNormative Statementsno
Req-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-952Epinephrine in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of epinephrine used during resuscitation.Birth InformationNormative Statementsno
Req-953Normal saline in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of normal saline solution used during resuscitation.Birth InformationNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
Req-955Na-bicarbonate in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of sodium bicarbonate used during resuscitation.Birth InformationNormative Statementsno
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
Req-957Record delivery room procedures2013 FormatThe system SHALL record any procedures performed in the delivery room including intubation, thoracocentesis, line placement, etc., and their timing.Birth InformationNormative Statementsno
Req-958Surfactant administration in delivery room2013 FormatThe system SHALL record any surfactant administration in the delivery room.Birth InformationNormative Statementsno
Req-959Adjust head circumference display for prematurity2013 FormatThe system SHALL be able to display head circumference adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsyes
Req-960Adjust length display for prematurity2013 FormatThe system SHOULD be able to display length adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
Req-961Adjust weight display for prematurity2013 FormatThe system SHOULD be able to display weight adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
Req-962Display head circumference data on growth charts2013 FormatThe system SHALL be able to display all recorded head circumference data on the sex-specific growth chart.Growth DataNormative Statementsno
Req-964CHIPRA-required quality measures2013 Format
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood...
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood immunization status in a clinic over 1 year beginning in January 2011, or weight assessment for children/adolescents over 2 months beginning in March 2011.
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Quality MeasuresNormative Statementsno
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.
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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
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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.
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
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Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-1008Manage Data Associated with Breast Milk Storage and Administration2013 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.
Well Child/Preventive CareFunctionno
Req-1009Manage data associated with breast milk products2013 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.
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.
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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.
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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.
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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-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-1040Developmental Scores / Intelligence Tests2013 FormatDevelopmental scores and scales are critical to assessing developmental milestones.Specialized Scales/ScoringFunctionno
Req-1041PEDS screen2013 FormatThe system SHALL support the PEDS screen.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-1043Bayley Scales of Infant Development2013 Format