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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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Req-108Support for Health Maintenance: Preventive Care and Wellness2013 FormatSystem supports Preventive Care and Wellness aspects of health maintenance.Activity Clearance, EPSDT, Newborn Screening, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareHeaderno
Req-122Manage Patient Clinical Measurements2013 Format
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of...
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of care. Other clinical measures (such as expiratory flow rate, size of lesion, etc. are captured and managed, and may be discrete data.
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EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive CareFunctionno
Req-129Present Alerts for Preventive Services and Wellness2013 Format
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider...
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider or patient is presented with due or overdue activities based on protocols for preventive care and wellness. Examples include but are not limited to, routine immunizations, adult and well child care, age and gender appropriate screening exams, such as PAP smears. The provider may wish to provide reminders to the patient based on the alert.
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EPSDT, Newborn 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.
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Activity Clearance, Birth Information, EPSDT, Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, 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-257Manage Immunization Administration2013 Format
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance...
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient's immunization history.
DESCRIPTION: During an encounter, recommendations based on accepted immunization schedules are presented to the provider. Allergen and adverse reaction histories are checked prior to giving the immunization. If an immunization is administered, discrete data elements associated with the immunization including date, type, manufacturer and lot number are recorded. Any new adverse or allergic reactions are noted. If required, a report is made to the public health immunization registry.
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Activity Clearance, EPSDT, Immunizations, Registry LinkagesFunctionno
Req-265Notifications and Reminders for Preventive Services and Wellness2013 Format
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are...
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are due or overdue and these communications can be captured. Examples include but are not limited to time sensitive patient and provider notification of: follow-up appointments, laboratory tests, immunizations or examinations. The notifications can be customized in terms of timing, repetitions and administration reports. E.g. a PAP test reminder might be sent to the patient two months prior to the test being due, repeated at three month intervals, and then reported to the administrator or clinician when nine months overdue.
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EPSDT, Newborn Screening, Patient Portals - PHR, Well Child/Preventive CareFunctionno
Req-269Support for Standard Care Plans, Guidelines, Protocols2013 Format
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and...
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported.
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EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
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.
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Activity Clearance, Birth Information, EPSDT, Well Child/Preventive CareFunctionno
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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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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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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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-290Support for Condition Based Care and Treatment Plans, Guidelines, Protocols2013 FormatSystem supports Condition Based Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-291Care and Treatment Plans, Guidelines and Protocols2013 FormatSystem maintains Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-639Access to age-specific guidelines2013 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.
EPSDT, Well Child/Preventive CareNormative Statementsyes
Req-690Recommend required immunizations per schedules2013 FormatThe system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.EPSDT, ImmunizationsNormative Statementsno
Req-972Age-specific preventive encounters2013 FormatThe system SHALL support age-specific preventive well-child encounters with content based on age-appropriate recommendations such as Medicaid EPSDT (Early and Periodic Screening, Diagnostic & Treatment and Bright Futures periodicity schedules.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-978Physical exam screening results2013 FormatThe system SHALL allow documentation of the presence or absence of age- and gender-specific physical exam findings.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-983Prompts for re-screening2013 FormatThe system SHOULD provide prompts regarding re-screening.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1073Age-specific screening forms2013 FormatThe system SHOULD support age-specific screening forms, including forms with content based on age-appropriate recommendations such as state-designated EPSDT (Early and Periodic Screening, Diagnostic & Treatment tools and Bright Futures Guidelines.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1085Prioritized list of recommended preventive care2013 FormatThe system SHOULD provide a prioritized list of recommended age specific preventive care based on a patient's previously completed preventive care, documented risk factors, and interest in specific preventive care.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1086Age-appropriate notifications2013 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.
EPSDT, Patient Portals - PHR, Well Child/Preventive CareNormative 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-1286Abnormal screen follow-up2013 FormatThe system SHOULD provide prompts to follow-up after an abnormal screening result.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1287Referral for dental services2013 FormatThe system SHOULD facilitate a dental referral according to the appropriate periodicity schedule (generally by age one or at eruption of the first tooth, and biannually thereafter or whenever indicated by abnormal findings.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1288Fluoride varnish and dental sealants2013 FormatThe system SHOULD alert when application of fluoride varnish or dental sealant is due. and support management and tracking of this service whether provided by the primary care provider or through a referral.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1289Blood-lead testing2013 FormatThe system SHOULD alert when blood-lead testing is needed.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1290EPSDT reporting2013 FormatThe system SHOULD be able to generate reports of recommended EPSDT (Early and Periodic Screening, Diagnostic & Treatment services to support annual EPSDT reporting requirements.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-2020Physical exam screening results2015 Priority ListThe system shall allow documentation of the presence or absence of pediatric age- and sex-specific physical exam findings.Well Child/Preventive Care, EPSDTNormative Statementyes
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