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 1-44 of 44
remove Filtering Topic Area on Child Welfare
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-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-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-253Manage Allergy, Intolerance and Adverse Reaction List2013 Format
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates,...
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s includes all reactions including those that are classifiable as a true allergy, intolerance, side effect or other adverse reaction to drug, dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are maintained.
Show Full Text
Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive CareFunctionno
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-263Manage Problem List2013 Format
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists...
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of historical information and tracking the changing character of problem(s and their priority. The source (e.g. the provider, the system id, or the patient of the updates should be documented. In addition all pertinent dates are stored. All pertinent dates are stored, including date noted or diagnosed, dates of any changes in problem specification or prioritization, and date of resolution. This might include time stamps, where useful and appropriate. The entire problem history for any problem in the list is viewable.
Show Full Text
Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, 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.
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-279Support Clinical Communication2013 Format
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs...
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs of healthcare-related communications, and provides automatic tracking and reporting. The list of communication participants is determined by the care setting and may change over time. Because of concerns about scalability of the specification over time, communication participants for all care settings or across care settings are not enumerated here because it would limit the possibilities available to each care setting and implementation. However, communication between providers and between patients and providers will be supported in all appropriate care settings and across care settings. Implementation of the EHRS enables new and more effective channels of communication, significantly improving efficiency and patient care. The communication functions of the EHRS will eventually change the way participants collaborate and distribute the work of patient care.
Show Full Text
Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
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-294Security2013 Format
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce...
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce security, all EHR-S applications must adhere to the rules established to control access and protect the privacy of EHR information. Security measures assist in preventing unauthorized use of data and protect against loss, tampering and destruction. An EHR-S must be capable of including or interfacing with standards-conformant security services to ensure that any Principal (user, organization, device, application, component, or object accessing the system or its data is appropriately authenticated, authorized and audited in conformance with local and/or jurisdictional policies.

An EHR-S should support Chains of Trust in respect of authentication, authorization, and privilege management, either intrinsically or by interfacing with relevant external services.
Show Full Text
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security...
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security and Confidentiality
Show Full Text
Headerno
Req-484Document communication with providers or agencies2013 FormatThe system SHALL provide the ability to document in the patient record verbal/telephone communication with providers or agencies whether internal or external to the organization.Child Welfare, Primary Care ManagementNormative Statementsno
Req-570Support for Inter-Provider Communication2013 Format
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or...
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or jurisdictional law.
DESCRIPTION: Communication among providers involved in the care process can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room to asynchronous communication (for example, consult reports between physicians Some forms of inter-practitioner communication will be paper based and the EHR-S must be able to produce appropriate documents.
The system should provide for both verbal and written communication. These exchanges would include but not limited to consults, and referrals as well as possible exchanges within the office as part of the provision and administration of patient care (for example, the communication of new information obtained within the office environment during the process of administration of a tetanus shot while the patient is in the exam room
The system should support the creation and acceptance of paper artifacts where appropriate.
Show Full Text
Child Welfare, Primary Care ManagementFunctionno
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-580Historical 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.
Child WelfareNormative Statementsno
Req-694Registry and Directory Services2013 Format
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and...
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and employers for administrative and financial purposes;
- public health agencies for healthcare purposes, and
- healthcare resources and devices for resource management purposes.
DESCRIPTION: Registry and directory service functions are critical to successfully managing the security, interoperability, and the consistency of the health record data across an EHR-S. These services enable the linking of relevant information across multiple information sources within, or external to, an EHR-S for use within an application.
Directories and registries support communication between EHR Systems and may be organized hierarchically or in a federated fashion. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider's EHR-S interrogates a local, regional, or national registry to find the patient's previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules.
An example of local registry usage is an EHR-S application sending a query message to the Hospital Information System to retrieve a patient's demographic data.
Show Full Text
Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
Req-718Entity Access Control2013 Format
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of...
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of an EHR-S. To ensure that access is controlled, an EHR-S must perform authentication and authorization of users or applications for any operation that requires it and enforce the system and information access rules that have been defined.
Show Full Text
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
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-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-1207Manage progress summaries, assessments, and service plans2013 FormatThe system SHOULD retrieve, capture, store, and display a child's progress summaries, assessments, and service plans.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1210Pediatric conditions and supporting technology2013 FormatThe system SHALL provide the ability to access, capture, store, and display a child's active or chronic conditions and illnesses, mental illness, and technology support needs (ventilator, monitor, surgical site care, wound vac, etc.Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1211Manage child’s health history2013 FormatThe system SHALL provide the ability to access, capture, store, display, and manage a child's health history including medication lists, medication allergies, adverse reactions, and immunizations.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
Req-1215Family, psychosocial, and child welfare resources2013 FormatThe system SHOULD have the ability to store, retrieve, and display a list of family, psychosocial, and child welfare resources.Child WelfareNormative Statementsno
Req-1216Type of placement2013 FormatThe system SHALL have the ability to store, retrieve, and display the type of placement (e.g., voluntary placement, court ordered placementChild WelfareNormative Statementsno
Req-1217Adoption history2013 Format
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information...
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information captured might not be clinically relevant. Further, the decision support relying on family history may be irrelevant and therefore the EHR system should exclude family history of adoptee in decision support logic.
Show Full Text
Child WelfareNormative Statementsno
Req-1218Authorized non-clinician viewers of EHR data2013 FormatThe system SHOULD have the ability to display clinical information to authorized non-clinician viewers of EHR data, such as child welfare case workers and other authorized members of the child's care team.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-1219Authorized user details2013 FormatThe system SHALL have the ability to capture and display the name, contact information, and relationship/role of each authorized viewer of EHR data.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-1220Clinical issues displayed to non-clinicians2013 FormatThe system SHOULD have the ability to display known interaction effects, known concerns and side-effects, or contraindications to authorized viewers of data external to clinicians, such as child welfare case workers.Child WelfareNormative Statementsno
Req-1221Placement setting in out-of-home care2013 FormatThe system SHALL have the ability to store, retrieve and display the current placement setting of the child in out-of-home care.Child WelfareNormative Statementsno
Req-1222Rights to authorize care and release information2013 FormatThe system SHALL have the ability to store, retrieve, and display information about rights to authorize care and to release information, as well as relevant consent forms.Child Welfare, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1223Out-of-home care history2013 FormatThe system SHALL have the ability to store, retrieve, and display whether the child has ever been in out-of-home care (yes or no is sufficientChild WelfareNormative Statementsno
Req-1224Dates of out-of-home care2013 FormatFor children who have ever been in out-of-home care, the system SHOULD have the ability to store and display information about the dates of the out-of-home care.Child WelfareNormative Statementsno
Req-1225Welfare court proceedings and legal status2013 FormatThe system SHOULD store, retrieve, and display the stage of court proceedings and legal status (e.g., court ordered placement in out of home care, detained, pre-adjudication versus sentenced, post-adjudication when available.Child WelfareNormative Statementsno
Req-1226Identification of additional births for parents with prior Termination of Parental Rights2013 FormatThe system MAY have the ability to connect with vital records to identify additional births to parents who have had a prior Termination of Parental Rights, when available.Child WelfareNormative Statementsno
Req-1227Legal history2013 FormatThe system SHOULD have access to the legal history (e.g., first-time offender versus repeat offender, multiple incarcerations when available.Child WelfareNormative Statementsno
Req-1229State agencies providing services2013 FormatThe system SHOULD have access to whether the child is being served by any other state agency and list each agency, when available.Child WelfareNormative Statementsno
Req-1230Medicaid case number2013 FormatThe system SHALL have the ability to store, retrieve, and display information about the child's Medicaid case number.Child WelfareNormative Statementsno
Req-1231Alert for foster care without Medicaid2013 FormatThe system SHALL have the ability to provide an option to alert where a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementsno
Req-1278History of Abuse and Neglect2013 FormatHistory of Abuse and NeglectChild Abuse Reporting, Child Welfare, Well Child/Preventive CareFunctionno
Req-2031Adoption history2015 Priority ListThe system shall have the ability to record a child's adoption history.Child WelfareNormative Statementyes
Req-2032Authorized non-clinician viewers of EHR data2015 Priority ListThe system shall have the ability to identify members of the care team (including professional and nonprofessional members and indicate their roles/relationships to the child.Child Welfare, Patient Portals - PHRNormative Statementyes
Req-2033Placement setting in out-of-home care2015 Priority ListThe system shall have the ability to record a child’s history of and/or current placement in foster care, with relevant date(s in care.Child WelfareNormative Statementyes
Req-2034Alert for foster care without Medicaid2015 Priority ListThe system shall have the ability to provide an option to alert when a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementyes
Scroll To Top