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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-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-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-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-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-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-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-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-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
Req-901Capture and record Birth Order for Multiple Births2013 FormatIf an infant is not a singleton, the system SHALL record the birth order.Birth Information, Patient IdentifierNormative Statementsno
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
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-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-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-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-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-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-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-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-579Report demographic data2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Birth Information, Child WelfareNormative Statementsno
Req-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-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-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-838Precise birth date and time storage2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Birth InformationNormative Statementsno
Req-837Precise birth date and time entry2013 FormatThe system SHALL enable entry of the date and time of birth (no less precisely than to the minute if required by the scope of practice.Birth InformationNormative Statementsyes
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
Req-957Record delivery room procedures2013 FormatThe system SHALL record any procedures performed in the delivery room including intubation, thoracocentesis, line placement, etc., and their timing.Birth InformationNormative Statementsno
Req-958Surfactant administration in delivery room2013 FormatThe system SHALL record any surfactant administration in the delivery room.Birth InformationNormative Statementsno
Req-952Epinephrine in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of epinephrine used during resuscitation.Birth InformationNormative Statementsno
Req-953Normal saline in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of normal saline solution used during resuscitation.Birth InformationNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
Req-955Na-bicarbonate in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of sodium bicarbonate used during resuscitation.Birth InformationNormative Statementsno
Req-948Neonatal Resuscitation2013 FormatResuscitation is common in the delivery room and the steps taken must be documented as part of the record.Birth InformationFunctionno
Req-949Respiratory support in neonatal resuscitation2013 FormatThe system SHALL record respiratory support used during resuscitation (Blow-by O2, Nasal Cannula O2, Bag / Mask Ventilation, CPAP, or Endotracheal IntubationBirth InformationNormative Statementsno
Req-950FiO2 administration in neonatal resuscitation2013 FormatThe system SHALL record the FiO2 delivered to the infant during resuscitation.Birth InformationNormative Statementsno
Req-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-944Oxygen saturation in delivery room2013 FormatThe system SHALL record percutaneous oxygen saturation measurements in the delivery room.Birth InformationNormative Statementsno
Req-945Clinical staff at delivery2013 FormatThe system SHALL record the pediatrician(s nurse(s and respiratory therapist(s present at delivery.Birth InformationNormative Statementsno
Req-947Neonatal physical exam2013 FormatThe system SHALL record the physical exam of the neonate.Birth InformationNormative Statementsno
Req-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.Birth InformationNormative Statementsno
Req-937Record delivery assistance2013 FormatThe system SHALL record if any delivery assistance was required (No Assistance, Forceps, Mid Forceps, High Forceps, or Vacuum ExtractionBirth InformationNormative Statementsno
Req-936Record mechanism of delivery2013 FormatThe system SHALL record the mechanism of delivery (Spontaneous Vaginal Delivery or SVD, Assisted Vaginal Delivery, Precipitous Vaginal Delivery, Emergent Cesarean section, Elective Cesarean sectionBirth InformationNormative Statementsno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth InformationNormative Statementsno
Req-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-935Record color of amniotic fluid2013 FormatThe system SHALL record the color of amniotic fluid (clear, cloudy, bloody, light meconium, moderate meconium, thick meconium, terminal meconiumBirth InformationNormative Statementsno
Req-934Rupture of membranes details2013 FormatThe system SHALL record if rupture of membranes was spontaneous (SROM artificial (AROM premature (PROM or preterm, premature (PPROMBirth InformationNormative Statementsno
Req-929Record tocolytics administration2013 FormatThe system SHALL record whether mother received tocolytics and, if so, which one(sBirth InformationNormative Statementsno
Req-928Perinatal magnesium sulfate administration2013 FormatThe system SHALL record whether the mother received magnesium sulfate doses prior to or during delivery.Birth InformationNormative Statementsno
Req-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
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