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Req-9391 minute Apgar2013 FormatThe system SHALL record Apgar score at 1 minute (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-9405 minute Apgar2013 FormatThe system SHALL record Apgar score at 5 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-94110 minute Apgar2013 FormatThe system SHALL record Apgar score at 10 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-931Additional medications during pregnancy2013 FormatThe system SHALL record any additional prescription and non-prescription medications and supplements (with name, dose, frequency, and route that the mother took during pregnancy.Birth InformationNormative Statementsno
Req-918Alcohol use during pregnancy2013 FormatThe system SHALL record alcohol use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of alcohol used per day.Birth InformationNormative Statementsno
Req-2009Allow unknown patient sex2015 Priority List
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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.
Genetic information, Birth Information, Prenatal ScreeningNormative Statementyes
Req-923Amphetamine use during pregnancy2013 FormatThe system SHALL record amphetamine use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of amphetamine used per day.Birth InformationNormative Statementsno
Req-1197Auto-populate birth certificate2013 FormatThe system SHOULD be able to auto-populate a birth certificate.Birth InformationNormative Statementsno
Req-927Betamethasone prior to delivery2013 FormatThe system SHOULD record the date and time of all Betamethasone doses given to the mother prior to delivery.Birth InformationNormative Statementsno
Req-895Birth History2013 FormatBirth represents a significant milestone. Newborn babies undergo large physiologic changes that make them susceptible to medical problems in the perinatal period. An accurate birth history provides the foundation for good newborn and child health care.Birth Information, Patient Identifier, Specialized Scales/ScoringHeaderno
Req-93Birth date format2013 FormatThe system SHALL record Birth Date (MM:DD:YYYYBirth InformationNormative Statementsno
Req-1198Birth information to state vital statistics registry2013 FormatThe system SHOULD provide birth information to the appropriate state vital statistics registry.Birth Information, Registry LinkagesNormative Statementsno
Req-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
Req-897Birth weight in kg2013 FormatThe system SHALL record birth weight in kilograms to 3 decimal places.Birth InformationNormative Statementsno
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
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-901Capture and record Birth Order for Multiple Births2013 FormatIf an infant is not a singleton, the system SHALL record the birth order.Birth Information, Patient IdentifierNormative Statementsno
Req-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-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-297Clinical Support2013 FormatSystem provides Clinical Support.
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well...
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-945Clinical staff at delivery2013 FormatThe system SHALL record the pediatrician(s nurse(s and respiratory therapist(s present at delivery.Birth InformationNormative Statementsno
Req-921Cocaine use during pregnancy2013 FormatThe system SHALL record cocaine use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of cocaine used per day.Birth InformationNormative Statementsno
Req-583Compute post conceptional age2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Birth Information, Growth Data, Prenatal ScreeningNormative Statementsno
Req-942Continuing Apgar scores2013 FormatThe system MAY record Apgar score at every 5 minutes after 10 minutes if the total score is less than; 5 (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-1007Copy and paste selected information from another medical record/chart2013 Format
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL...
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL support suppression of the maternal identity in cases that require parental confidentiality (e.g. voluntary surrender for adoption, or removal from the mother's care for other reasons
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Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-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-952Epinephrine in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of epinephrine used during resuscitation.Birth InformationNormative Statementsno
Req-950FiO2 administration in neonatal resuscitation2013 FormatThe system SHALL record the FiO2 delivered to the infant during resuscitation.Birth InformationNormative Statementsno
Req-899Gestational age based on Dubowitz or Ballard2013 FormatThe system SHALL record gestational age in weeks based on Dubowitz scoring or Ballard Exam.Birth InformationNormative Statementsno
Req-898Gestational age in weeks and days2013 FormatThe system SHALL record gestational age in weeks and days based on last menstrual period (LMP ultrasound, or maternal report.Birth InformationNormative Statementsyes
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
Req-924Illicit drug use during pregnancy2013 FormatThe system SHALL record other illicit drugs used during pregnancy (Positive, Negative, or Unknown IF positive THEN the system SHALL record the name, dose and frequency of use.Birth InformationNormative Statementsno
Req-582Indicate unknown patient gender2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-902Infant size relative to gestational age2013 FormatThe system SHALL provide the ability to capture, record and store the birth weight, length and head circumference of the infant relative to normal values for its captured and/or assigned gestational age (SGA=Small for Gestational Age, AGA=Appropriate for Gestational Age, LGA=Large for Gestational AgeBirth InformationNormative Statementsno
Req-938Initial Infant Data2013 FormatData recorded in the first hour of life will guide care in the initial neonatal period.Birth Information, Specialized Scales/ScoringFunctionno
Req-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth InformationNormative Statementsno
Req-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-2001Link maternal and birth data to child health record2015 Priority ListThe system shall import birth information from an electronic newborn discharge summary as discrete data elements.
All other requirements, such as gestation age, can be incorporated into a birth data elements list.
Birth InformationNormative Statementyes
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-268Manage Patient History2013 Format
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient...
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.
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Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening,...
Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening, Primary Care Management, Security and Confidentiality, Specialized Scales/Scoring, Well Child/Preventive Care
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Functionno
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-912Maternal HIV status2013 FormatThe system SHALL record maternal HIV status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-911Maternal VDRL status2013 FormatThe system SHALL record maternal syphilis status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-915Maternal chlamydia status2013 FormatThe system SHALL record maternal chlamydia Status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
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