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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-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, Well Child/Preventive CareHeaderno
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.
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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
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Functionno
Req-256Manage Consents and Authorizations2013 Format
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment...
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
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Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Functionno
Req-262Manage Patient-Specific Care and Treatment Plans2013 Format
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the...
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
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Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareFunctionno
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.
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Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, 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.
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Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
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.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-281Documentation of Care, Measurements and Results2013 FormatSystem will document Care, Measurements and Results
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages,...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive Care
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Headerno
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-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, Well Child/Preventive CareHeaderno
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
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Headerno
Req-285Administrative and Financial2013 FormatSystem supports Administrative and Financial functions.Children with Special Healthcare Needs, Genetic information, Registry Linkages, Specialized Scales/Scoring, 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
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Headerno
Req-287Preferences, Directives, Consents and Authorizations2013 FormatMaintain preferences, directives, consents and authorizations.
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Headerno
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
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-456Support the capture of coded age based, disease specific measures2013 FormatThe system SHALL support the capture of coded age based, disease specific measures used in the characterization and/or categorization of disease severity (e.g. Asthma: National Heart Lung and Blood Institute Asthma Severity Tool; depression; ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-457Support the capture of coded pediatric functional health status measures2013 FormatThe system SHALL support the capture of coded pediatric functional health status measures (e.g. ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-458Coded disease measure goals and thresholds2013 FormatThe system SHOULD capture/calculate coded individualized disease measure goals and thresholds for modifying care (e.g. peak flow, FEV1, HgA1c, or behavioral goals used in self-care and inpatient treatment plansChildren with Special Healthcare Needs, Primary Care Management, Quality MeasuresNormative Statementsno
Req-461Support the addition or exclusion of patients from registries by authorized users2013 FormatThe system SHOULD support the addition or exclusion of patients from registries by authorized users and capture addition or exclusion criteria.Children with Special Healthcare NeedsNormative Statementsno
Req-471Access to patient data-specific materials2013 FormatThe system SHOULD provide access to display and print relevant provider/layperson treatment procedure standards/training; medical/psychological/behavioral condition education materials; and related management guidelines based on coded patient data in the system (e.g. InfobuttonChildren with Special Healthcare Needs, Patient Portals - PHRNormative Statementsno
Req-472Communicate with local service registries2013 FormatThe system SHOULD provide the ability to search, view, and contribute to local service registries that include providers, medical home practices or services, durable medical equipment (DME skilled nursing facilities (SNF social service programs, etc. and detail services, insurance affiliation, and preferred contact method for notes, referrals, and orders.Children with Special Healthcare NeedsNormative Statementsno
Req-564Support for Referral Process2013 Format
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof...
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof are presented to the provider. Standardized or evidence based protocols for appropriate workup prior to referral may be presented.
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Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-565Orders, Referrals, Results and Care Management2013 FormatSystem supports Orders, Referrals, Results and Care Management.Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareHeaderno
Req-577Measurement, Monitoring, and Analysis2013 FormatSTATEMENT: Support measurement and monitoring of care for relevant purposesChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-602Document using standard assessments2013 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.
Children with Special Healthcare NeedsNormative 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.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
Req-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
Req-730Flag special healthcare needs2013 FormatThe system SHALL support the flagging of individuals with special healthcare needs or complex conditions, to facilitate care management, decision support, and reporting.Children with Special Healthcare NeedsNormative Statementsno
Req-732Ability to search service registries2013 FormatService registry entries SHOULD be searchable by name, location, service categories provided, and/or parent organization.Children with Special Healthcare NeedsNormative Statementsno
Req-739Support for Monitoring Response Notifications Regarding a Specific Patient’s Health2013 Format
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that...
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that expected follow-up for a specific patient event (e.g., follow up to error alerts or absence of an expected lab result has not occurred and communicate the omission to appropriate care providers in the chain of authority. The notification process requires a security infrastructure that provides the ability to match a care provider's clinical privileges with the clinical requirements of the notification.
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Children with Special Healthcare NeedsFunctionno
Req-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
Req-847Head Circumference2013 FormatHead circumference is typically measured in newborns and then at every well-child visit through 36 months of life. Head circumference may also be measured at other times based on clinician concern, or in cases of chronic neurologic disease or developmental delayChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-850Display head circumference on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-855Weight2013 FormatWeight is typically measured in newborns and then at every patient encounter.Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-860Display weight data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-862Ability to record tare weight for DME2013 FormatThe system SHALL allow recording of tare weight for durable medical equipment such as wheelchairs and walkers to facilitate easy weighing of children with special needs.Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-863Body Mass Index2013 FormatBody mass index (BMI is a calculated, based on weight and height. Currently, normative data exist only for children 2 and older. It is usually measured at all well-child visits, but can be assessed at other times based on clinician concern.Children with Special Healthcare Needs, Growth Data, Well Child/Preventive CareFunctionno
Req-867Display BMI data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-1057Use and search of pediatric diagnosis codes2013 FormatThe system SHALL support the use and search of a broad selection of pediatric diagnosis codes and code sets, when available, such as by specialty, subspecialty or organ system.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsyes
Req-1058Manage language preferences2013 FormatThe system SHALL capture the child's preferred language, including sign language (separately from that of the parent/caregiver and whether an interpreter is necessary.Children with Special Healthcare NeedsNormative Statementsno
Req-1059Code status for children with special healthcare needs2013 FormatThe system MAY selectively include code status on the Health & Physical Evaluation template for a child designated as medically complex and/or with special health care needs.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsno
Req-1060Clinical decision support for code status2013 FormatThe system SHOULD support the ability to prompt for the provider (appropriate to local processes and workflow to discuss code status with the parent/guardian of a medically complex child with special health care needs upon an initial health & physical evaluation.Children with Special Healthcare NeedsNormative Statementsno
Req-1061Hospice and palliative care needs2013 FormatThe system SHALL capture hospice and palliative care needs for the child with identification of age-appropriate resources.Children with Special Healthcare NeedsNormative Statementsno
Req-1062DME and nursing needs2013 FormatThe system SHALL capture Durable Medical Equipment (DME and nursing needs for the child with identification of age-appropriate resources and orderables.Children with Special Healthcare NeedsNormative Statementsno
Req-1063Support the population of patient registries based on specific data2013 FormatThe system SHALL support the population of patient registries based on specific demographic information (including age clinical findings, diagnoses, medications, and financial/payor criteria.Children with Special Healthcare Needs, Genetic information, ImmunizationsNormative Statementsno
Req-1064Ability to send non-medication orders, referrals, and updates to receiving systems2013 Format
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company,...
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company, home care provider, case management, and mental, dental, and visual health services, when standard interfaces are available.
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Children with Special Healthcare NeedsNormative Statementsno
Req-1065Ability to route and track patient disease management plans, etc. to recipients in local registry2013 FormatThe system MAY provide the ability to version, route and track patient disease management plans, school medication administration forms, early intervention and WIC referrals, etc. to recipients in local service provider registry by preferred routing method (e.g. fax or electronicChildren with Special Healthcare NeedsNormative Statementsno
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