United States Health Information Knowledgebase

 

You are viewing the Abridged Children's EHR Format.
To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.

Results 1-100 of 695
remove Filtering Release Package on 2013 Format
MS Excel
Download as an MS Excel spreadsheet.
[Download Excel ReaderExit Disclaimer]
PDF
Download as a PDF file.
[Download PDF ReaderExit Disclaimer]
MS Word
Download as an MS Word document.
[Download Word ReaderExit Disclaimer]
Remove All Filters

sort Req ID
sort Title
sort Release Package
Release Package(s) Selected
sort Description
sort Topic Area
Topic Area(s) Selected
sort Type
Type(s) Selected
sort Critical/Core
Critical/Core(s) Selected
Req-1037Wong-Baker FACES pain scale2013 FormatThe system SHALL support the Wong-Baker FACES pain scale.Specialized Scales/ScoringNormative Statementsno
Req-1185Well-being measures relevant to child welfare2013 Format
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known...
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known diseases, etc., (2 Education: school name and date (the child can be transient presence of an IEP or 504 plan, (3 School performance: above, at, or below grade level; number of absences (excused or unexcused graduation date or presence of a GED, etc., (4 Employment and/or Higher Education: employment status; taking post-HS courses or not.
Show Full Text
Child Abuse Reporting, Child Welfare, Well Child/Preventive CareNormative Statementsno
Req-1225Welfare court proceedings and legal status2013 FormatThe system SHOULD store, retrieve, and display the stage of court proceedings and legal status (e.g., court ordered placement in out of home care, detained, pre-adjudication versus sentenced, post-adjudication when available.Child WelfareNormative Statementsno
Req-1240Weight-specific daily dose range checking2013 FormatThe system SHALL inform the user when a daily dose has exceeded (or is planned to exceed the recommended range for patient size or maximum recommended adult dose, whichever is smaller.Medication ManagementNormative Statementsno
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-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-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-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-1131Vaccine reminders2013 FormatThe system MAY provide the ability to link to (and display vaccine dose reminders from recognized health maintenance standards.ImmunizationsNormative Statementsno
Req-1116Vaccine administration messages to billing system2013 FormatThe system SHOULD send standard messages to the practice management/billing system that include vaccine-specific administration codes.Immunizations, Medication ManagementNormative Statementsno
Req-1252User guidance based on age of consent2013 FormatThe system MAY provide user guidance based on patient age for consent and assent according to organizational policy or jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-627User Interface preferences2013 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.
Growth Data, Specialized Scales/ScoringNormative Statementsno
Req-1139Use established immunization messaging standards2013 FormatThe system SHALL provide the ability to use established and agreed upon messaging standards to transmit and receive data from Immunization Information Systems (IISs and other Health Information Exchanges (HIEsImmunizations, Registry LinkagesNormative Statementsno
Req-643Use demographic-specific norms to manage care2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1057Use and search of pediatric diagnosis codes2013 FormatThe system SHALL support the use and search of a broad selection of pediatric diagnosis codes and code sets, when available, such as by specialty, subspecialty or organ system.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsyes
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-612Update immunization schedule on demand2013 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.
ImmunizationsNormative Statementsno
Req-1112Update immunization inventory on vaccine dose administration2013 FormatIF the system links to a vaccine inventory (formulary THEN the system SHOULD update the inventory/formulary when a vaccine dose is administered and documented.ImmunizationsNormative Statementsno
Req-834Unit-specific calculation2013 FormatUnit-specific calculationWell Child/Preventive CareFunctionno
Req-990Unique newborn identifiers2013 FormatThe system SHALL generate a unique identifier for each newborn.Patient IdentifierNormative Statementsno
Req-1216Type of placement2013 FormatThe system SHALL have the ability to store, retrieve, and display the type of placement (e.g., voluntary placement, court ordered placementChild WelfareNormative 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-1134Transmit data on vaccine refusals to IIS2013 FormatThe system SHALL provide the ability to transmit data on vaccine refusals to Immunization Information Systems (IISs using an established and agreed upon messaging standard.Immunizations, Registry LinkagesNormative Statementsno
Req-1165Transition of self care from pediatric to adult care2013 FormatThe system SHOULD support transition of care from pediatric to adult care in regards to self-care management and care planning.Primary Care ManagementNormative Statementsno
Req-1163Transition of medical records2013 FormatThe system SHOULD support transition of medical records from pediatric to adult care.Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1169Transition of care coordination from pediatric to adult care2013 FormatThe system SHOULD support transition of care from pediatric to adult care in regards to coordination of care.Primary Care ManagementNormative Statementsno
Req-1095Transferrable access authority2013 FormatThe system SHALL provide a mechanism to enable access control that allows a transferrable access authority.Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityNormative Statementsno
Req-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-1126Timely decision support when ordering vaccines2013 Format
The system SHALL enable timely decision support (recommendations for specific antigens when ordering vaccine dose(s for an individual patient, based on a current child health immunization schedules, which may include the patient's immunization history (age,...
The system SHALL enable timely decision support (recommendations for specific antigens when ordering vaccine dose(s for an individual patient, based on a current child health immunization schedules, which may include the patient's immunization history (age, vaccines received, including date of last previous vaccination b the patient's demographics (date of birth and clinical history (current weight, allergies, medications, problem lists, and laboratory test results including contraindications to vaccine components, and c an entered date (default date is the time the vaccine is ordered, i.e. Now
Show Full Text
ImmunizationsNormative Statementsyes
Req-1248Time stamp consent to guardianship2013 FormatThe system SHOULD record the date and time of consent to guardianship when transferred from biological relationship, e.g., mother, father, or kinships, foster or custodial care, or proxy.Security and ConfidentialityNormative 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-631Templates to facilitate documentation2013 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.
Primary Care Management, 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-1039Tanner stages of adolescent development2013 FormatThe system SHALL support the Tanner stages of adolescent development.Specialized Scales/ScoringNormative 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-611Synchronize immunization histories with registry2013 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.
Immunizations, Registry LinkagesNormative Statementsyes
Req-903Symmetry2013 FormatThe system SHALL record symmetry at birth as Symmetrical or Asymmetrical.Birth InformationNormative Statementsno
Req-1187Suspected abuse and neglect information from standardized questions2013 FormatThe system SHOULD provide the ability to capture suspected abuse and neglect information via standardized intake questions with answers being provided on a standard scale to indicate the alleged abuse.Child Abuse ReportingNormative Statementsno
Req-958Surfactant administration in delivery room2013 FormatThe system SHALL record any surfactant administration in the delivery room.Birth InformationNormative Statementsno
Req-722Supportive Function Maintenance2013 FormatSTATEMENT: Update EHR supportive content using a manual or automated process.Well Child/Preventive CareHeaderno
Req-1267Support validated developmental screening tools2013 FormatThe system SHALL support the use and documentation of formal, validated best practice screening tools such as: ASQ, PEDS, M-CHAT, PSC, etc.Well Child/Preventive CareNormative Statementsyes
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-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.
Show Full Text
Registry LinkagesNormative Statementsno
Req-1063Support the population of patient registries based on specific data2013 FormatThe system SHALL support the population of patient registries based on specific demographic information (including age clinical findings, diagnoses, medications, and financial/payor criteria.Children with Special Healthcare Needs, Genetic information, ImmunizationsNormative 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-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-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-1006Support prescription details2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Medication ManagementNormative Statementsno
Req-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-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-1091Support organizational configuration for well and preventive care alerts and reports2013 FormatThe system SHOULD support age-specific organizational configuration of rules, links, and content for well and preventive care alerts and reports.Well Child/Preventive CareNormative 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-1067Support incremental interoperability standards2013 FormatThe system SHOULD support incremental interoperability standards between EHRs and school management systems, health service providers, and governmental agencies.Children with Special Healthcare NeedsNormative 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-1124Support for ordering immunizations2013 FormatSupport for ordering immunizationsImmunizationsFunctionno
Req-1117Support for immunization information output management2013 FormatSupport for immunization information output managementImmunizations, Well Child/Preventive CareFunctionno
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-660Support for age-appropriate referrals2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
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.
Show Full Text
EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
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.
Show Full Text
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-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.
Show Full Text
Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, Well Child/Preventive CareHeaderno
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.
Show Full Text
Immunizations, Medication ManagementFunctionno
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
Show Full Text
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
Show Full Text
Primary Care Management, Well Child/Preventive CareFunctionno
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.
Show Full Text
Children with Special Healthcare NeedsFunctionno
Req-292Support for Medication and Immunization Ordering2013 FormatSystem supports Medication and Immunization Ordering.Immunizations, Medication ManagementHeaderno
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.
Show Full Text
Immunizations, Medication Management, Registry LinkagesFunctionno
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.
Show Full Text
Medication ManagementFunctionno
Req-562Support for Knowledge Access2013 FormatSystem supports Knowledge Access.Well Child/Preventive CareHeaderno
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.
Show Full Text
Child Welfare, Primary Care ManagementFunctionno
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.
Show Full Text
Well Child/Preventive CareFunctionno
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-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-745Support for Accurate Specimen Collection2013 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.
Primary Care Management, Well Child/Preventive CareFunctionno
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-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-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-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-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-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-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.
Show Full Text
Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-1018Support Apgar scores2013 FormatThe system SHALL support Apgar scores.Specialized Scales/ScoringNormative 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-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
Show Full Text
Headerno
Req-1072Structured information from screening tool2013 FormatThe system SHOULD capture information from the screening tool in a structured form.Well Child/Preventive CareNormative Statementsno
Req-1103Store codified newborn screening results2013 FormatThe system SHALL be able to store standardized codified newborn screening results to the degree to which they are made available.Newborn ScreeningNormative Statementsno
Req-1182Store and retrieve restraining and visitation order information2013 FormatThe system SHALL provide the ability to access, store, and retrieve any restraining orders, visitation orders and the person or organization with decision making authority within the native EHR system.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
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.
Show Full Text
Well Child/Preventive CareHeaderno
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-1092Statistics reporting based on captured and existing data elements2013 FormatThe system SHOULD produce provider-, practice-, and organization- level statistics on provision of screening, preventive care, disease specific care, and follow-up per opportunity with the capability for comparisons to locally specified age-specific performance targets.Well Child/Preventive CareNormative Statementsno
Req-111Statistics for growth chart data2013 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.
Growth DataNormative Statementsno
Req-1229State agencies providing services2013 FormatThe system SHOULD have access to whether the child is being served by any other state agency and list each agency, when available.Child WelfareNormative Statementsno
Req-1045Stanford-Binet Intelligence Scale2013 FormatThe system SHALL support the Stanford-Binet Intelligence Scale.
REF: Binet, Alfred; Simon, Th. (1916 The development of intelligence in children: The Binet-Simon Scale. Publications of the Training School at Vineland New Jersey Department of Research No. 11. E. S. Kite (Trans. Baltimore: Williams & Wilkins. Retrieved 18 July 2010.
Specialized Scales/ScoringNormative Statementsno
Req-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.
Show Full Text
Immunizations, Prenatal Screening, Registry Linkages, School-Based LinkagesHeaderno
Req-1188Standardized CDC categorization for child abuse2013 FormatThe system SHOULD use the standardized CDC categorization for child abuse and neglect with the ability for states to utilize specific categorization both in the past history and current assessment. The Center for Disease Control and Prevention details further guidance on data definitions for child abuse and neglect.Child Abuse ReportingNormative 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
Scroll To Top