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 1-50 of 87
remove Filtering Topic Area on Birth Information
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-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-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-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-2009Allow unknown patient sex2015 Priority List
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.
Genetic information, Birth Information, Prenatal ScreeningNormative Statementyes
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-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
Show Full Text
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
Show Full Text
Headerno
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.
Show Full Text
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
Show Full Text
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-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.
Show Full Text
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.
Show Full Text
Activity Clearance, Birth Information, EPSDT, Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, 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.
Show Full Text
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.
Show Full Text
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
Req-284Measurement, Analysis, Research and Reports2013 FormatSystem supports measurement, analysis, research and reports.
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures,...
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Well Child/Preventive Care
Show Full Text
Headerno
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.
Show Full Text
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
Show Full Text
Functionno
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
Show Full Text
Headerno
Req-579Report demographic 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.
Birth Information, Child WelfareNormative Statementsno
Req-582Indicate unknown patient gender2013 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.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-583Compute post conceptional age2013 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.
Birth Information, Growth Data, Prenatal ScreeningNormative 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-838Precise birth date and time storage2013 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.
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-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-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-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.Birth InformationNormative 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-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-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-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
Scroll To Top