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 1-36 of 36
remove Filtering Topic Area on Child Abuse Reporting
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-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-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.
Show Full Text
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
Show Full Text
Functionno
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-286Summary Lists2013 FormatSystems ability to capture summary lists.
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family...
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
Show Full Text
Headerno
Req-512Support communication with national, state, and local Child Protective Services, and more2013 FormatThe system MAY communicate with national, state, and local Child Protective Services, law enforcement, care physicians, prosecutor, medical examiner, Medicaid, and Insurance companies.Child Abuse ReportingNormative Statementsno
Req-513Retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the victim, teen pregnancy and births.2013 FormatIn cases of child abuse the system SHOULD provide the ability to retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the patient, teen pregnancy and births.Child Abuse Reporting, Well Child/Preventive CareNormative Statementsno
Req-515Ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance.Child Abuse Reporting, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-517Ability to access family history, including all parents2013 FormatThe system SHALL provide the ability to access family history, including all parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers; with contact information for each.Child Abuse ReportingNormative Statementsno
Req-518Ability to retrieve, capture, store, and display information regarding forensic evaluations2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display information regarding forensic evaluations.Child Abuse ReportingNormative Statementsno
Req-519Ability to access, store, and retrieve the date, time, and place of the occurrence2013 FormatThe system SHALL provide the ability to access, store, and retrieve the date, time, and place of the occurrence of alleged abuse.Child Abuse ReportingNormative Statementsno
Req-520Ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings2013 FormatThe system SHALL provide the ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings (both sexual and physical documentation of laboratory studies, and radiographic studies.Child Abuse ReportingNormative Statementsno
Req-522Ability to retrieve, capture, store, and display service plans, progress summaries, and assessments2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display service plans, progress summaries, and assessments.Child Abuse ReportingNormative Statementsno
Req-1175Past history of abuse and neglect for the child2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect for the child.Child Abuse ReportingNormative Statementsno
Req-1176Past history of abuse and neglect by perpetrator2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect by the alleged perpetrator.Child Abuse ReportingNormative Statementsno
Req-1177Maintain unsubstantiated instances of abuse or neglect2013 Format
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability...
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability to expunge or limit communication to certain external systems unsubstantiated instances of abuse or neglect when required by the prevailing law.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1178Manage roles and permissions for child abuse data2013 FormatThe system SHOULD provide the ability to define and manage roles and permissions to access specific sections of the system with role-based access including, but not limited to, access to child abuse data by child welfare agents and physicians.Child Abuse ReportingNormative Statementsno
Req-1179History of termination of parental rights from within EHR2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of termination of parental rights documented within the native EHR system for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1180History of termination of parental rights from an external information source2013 FormatThe system MAY provide the ability to retrieve, capture, store, and display a past history of termination of parental rights from an external information source (e.g. registry for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1181Notification to child welfare per mandate2013 Format
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as...
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as state, tribal or other authority that child welfare be notified in instances of abuse that includes a past history of termination of parental rights.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1182Store and retrieve restraining and visitation order information2013 FormatThe system SHALL provide the ability to access, store, and retrieve any restraining orders, visitation orders and the person or organization with decision making authority within the native EHR system.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1183Access restraining and visitation order information from external source2013 FormatThe system MAY provide the ability to access, store, and retrieve from an external information source (e.g. registry any restraining or visitation orders, and the person or organization with decision making authority.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1184Data related to outcome measures for welfare agencies2013 FormatThe system SHOULD provide the ability to include data elements that are related to federally required outcome measures as may be requested by child welfare agencies.Child Abuse ReportingNormative Statementsno
Req-1185Well-being measures relevant to child welfare2013 Format
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known...
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known diseases, etc., (2 Education: school name and date (the child can be transient presence of an IEP or 504 plan, (3 School performance: above, at, or below grade level; number of absences (excused or unexcused graduation date or presence of a GED, etc., (4 Employment and/or Higher Education: employment status; taking post-HS courses or not.
Show Full Text
Child Abuse Reporting, Child Welfare, Well Child/Preventive CareNormative Statementsno
Req-1186Capture child abuse details2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history...
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history specific sexual acts; and mechanism of injury in separate sections (e.g. one section for alleged perpetrator and one section for child
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1187Suspected abuse and neglect information from standardized questions2013 FormatThe system SHOULD provide the ability to capture suspected abuse and neglect information via standardized intake questions with answers being provided on a standard scale to indicate the alleged abuse.Child Abuse ReportingNormative Statementsno
Req-1188Standardized CDC categorization for child abuse2013 FormatThe system SHOULD use the standardized CDC categorization for child abuse and neglect with the ability for states to utilize specific categorization both in the past history and current assessment. The Center for Disease Control and Prevention details further guidance on data definitions for child abuse and neglect.Child Abuse ReportingNormative Statementsno
Req-1189Disposition of abuse allegations within the EHR2013 Format
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions...
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1190Disposition of abuse allegations from external source2013 Format
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for...
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1191Mental health, learning, and developmental history2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's developmental stage, learning barriers, mental health history, and current therapy related to development, learning, or mental health/substance abuse (e.g., speech therapy, cognitive therapy, and antidepressantsChild Abuse Reporting, EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1192Family history relationships2013 Format
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents...
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.
Show Full Text
Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1193Link to Child Welfare registries2013 FormatThe system SHOULD provide an interface or link to child welfare registries to be searchable by name (either child or parent placement, service categories provided, and/or jurisdiction.Child Abuse Reporting, Child Welfare, Registry LinkagesNormative Statementsno
Req-1194EHR-documented abuse by caregivers2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day...
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1195Externally documented abuse by caregivers2013 Format
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed...
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
Show Full Text
Child Abuse ReportingNormative Statementsno
Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
Req-1278History of Abuse and Neglect2013 FormatHistory of Abuse and NeglectChild Abuse Reporting, Child Welfare, Well Child/Preventive CareFunctionno
Req-2006Ability to access family history, including all guardians and caregivers2015 Priority ListThe system shall provide the ability to record information about all guardians and caregivers (biological parents, foster parents, adoptive parents, guardians, surrogates, and custodians siblings, and case workers; with contact information for each.Child Abuse Reporting, Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementyes
Scroll To Top