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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-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-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-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-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-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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