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Req-93Birth date format2013 FormatThe system SHALL record Birth Date (MM:DD:YYYYBirth InformationNormative 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-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
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-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-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-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-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-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-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-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-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-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-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-117Calculate growth velocity2013 FormatThe system SHOULD calculate growth velocity between two points on the growth chart selected by the user.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-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-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-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-126Growth and body composition data2013 FormatSystem supports recording of growth and body composition measures, calculations, conversions, normal ranges, and trending.Growth DataHeaderno
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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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-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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