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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-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-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.
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Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive CareFunctionno
Req-258Manage Immunization List2013 Format
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured...
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured as discrete data elements including date, type, manufacturer and lot number. The entire immunization history is viewable.
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Activity Clearance, Immunizations, Medication ManagementFunctionno
Req-259Manage Medication List2013 Format
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start,...
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.
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Medication ManagementFunctionno
Req-272Support for Patient Specific Dosing and Warnings2013 Format
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g....
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g. pregnancy, breast-feeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, height, weight, and body surface area (BSA shall also be incorporated.
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Immunizations, Medication ManagementFunctionno
Req-273Support for Medication and Immunization Administration2013 Format
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To...
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a by-product of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured.
Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the "window" for timely administration of medications.
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Immunizations, Medication Management, Registry LinkagesFunctionno
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-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-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-292Support for Medication and Immunization Ordering2013 FormatSystem supports Medication and Immunization Ordering.Immunizations, Medication ManagementHeaderno
Req-293Medication and Immunization Management2013 FormatSystem manages Medications and ImmunizationsImmunizations, Medication Management, Registry LinkagesHeaderno
Req-296Standard Terminologies and Terminology Services2013 Format
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated...
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated by the consistency of human and machine interpretation of shared data and reports. It includes the capture and support of consistent data for templates and decision support logic.

Terminology standards pertain to concepts, representations, synonyms, relationships and computable (machine-readable definitions. Terminology services provide a common way for managing and retrieving these items.
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Medication Management, Special Terminology and InformationHeaderno
Req-451Closest available standardized dose2013 FormatThe system MAY inform the ordering provider about the closest available standardized dose after calculating the dose based on patient age and weight.Medication ManagementNormative Statementsno
Req-575Non-Medication Orders and Referrals Management2013 FormatManage Non-Medication Orders and ReferralsMedication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-597Capture medication dates2013 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.
Medication ManagementNormative Statementsno
Req-607Order blood products in pediatric units2013 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.
Medication ManagementNormative Statementsno
Req-646Compute weight-based drug dosage2013 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.
Medication ManagementNormative Statementsno
Req-648Alternative dosing weight2013 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.
Medication ManagementNormative Statementsyes
Req-649Combination drug dosage functions2013 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.
Medication ManagementNormative Statementsno
Req-655Indicate formulae for drug dose recommendations2013 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.
Medication ManagementNormative Statementsno
Req-680Manage Orders for Blood Products and Other Biologics2013 Format
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics...
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics including discontinuance orders. Use of such products in the provision of care is captured. Blood bank or other functionality that may come under jurisdictional law or other regulation (e.g. by the FDA in the United States is not required; functional communication with such a system is required.
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Medication ManagementFunctionno
Req-685Date of allergy documentation2013 FormatThe system SHALL provide the ability to capture and display the date on which allergy information was entered.Medication Management, Well Child/Preventive CareNormative Statementsno
Req-686Medication administration details2013 FormatThe system SHALL provide the ability to capture all pertinent details of the medication administration including medication name, strength, dose, route, time of administration, exceptions to administration, and administrator of the medication.Medication ManagementNormative Statementsno
Req-698Manage Non-Medication Patient Care Orders2013 Format
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and...
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and discontinue orders. Examples include orders to transfer a patient between units, to ambulate a patient, for medical supplies, durable medical equipment, home IV, and diet or therapy orders.
Each item ordered includes the appropriate detail, such as order identification and instructions. Orders should be communicated to the correct service provider for completion.
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Medication ManagementFunctionno
Req-703Support for Medication Recommendations2013 Format
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice...
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice standards (e.g. cost or adherence to guidelines a generic brand, a different dosage, a different drug, or no drug (watchful waiting Suggest lab order monitoring as indicated by the medication or the medical condition to be affected by the medication. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etc.
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Medication ManagementFunctionno
Req-715Standard Terminologies and Terminology Models2013 Format
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a...
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc. Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
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Medication Management, Special Terminology and InformationFunctionno
Req-740Manage Medication Orders2013 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.
Medication ManagementFunctionno
Req-881Document reasons for drug alert override2013 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.
Medication ManagementNormative Statementsno
Req-882Drug dosage computation2013 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.
Medication ManagementNormative Statementsyes
Req-883Future dose calculation factors2013 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.
Medication ManagementNormative Statementsno
Req-884Alert for invalid dose computation data2013 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.
Medication ManagementNormative Statementsno
Req-885Alert for unavailable pediatric dosing2013 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.
Medication ManagementNormative Statementsno
Req-886Liquid drug prescriptions2013 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.
Medication ManagementNormative Statementsno
Req-887Drug contraindications in specific child populations2013 FormatThe system SHOULD provide the ability to detect contraindications in specific child populations (e.g. age groups or those with liver issues for individual medications and any combined pharmacotherapy and inform the user during ordering.Medication ManagementNormative Statementsno
Req-888High risk drug combinations in children2013 FormatThe system SHALL provide the ability to detect high risk drug combination alerts specific to children and inform the user during ordering.Medication ManagementNormative Statementsyes
Req-890Indicate common side effects2013 FormatThe system MAY provide the ability to indicate common side effects, including those unique to or more common in children, and inform the user during ordering.Medication ManagementNormative Statementsno
Req-891Alternative administration techniques2013 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.
Medication ManagementNormative Statementsno
Req-892Child-appropriate doses in provider-specific medication lists2013 FormatThe system SHALL support child-appropriate dosing in provider specific medication lists ("favorites" including default route, dose, frequency, and quantity (e.g. accommodate weight-based doses such as <mg or mcg or gm>/kg/dose or <mg or mcg or gm>/kg/dayMedication ManagementNormative Statementsno
Req-893Documentation of compliance and refusal of care2013 FormatThe system MAY provide the ability to require documentation of information regarding patient compliance with prescribed treatment, including parent/guardian refusal of treatment.Medication ManagementNormative Statementsno
Req-894Require documentation of therapeutic labs2013 FormatThe system SHOULD provide the ability to require documentation of therapeutic labs or appropriate lab levels recommended for child dosing.Medication ManagementNormative Statementsno
Req-1006Support prescription details2013 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.
Medication ManagementNormative Statementsno
Req-1013Standard terminology for medications and treatments2013 Format
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use...
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use existing terminologies that represent clinical medications, such as MediSpan, First Data Bank or Multum to support this function. However, EHR systems may also maintain their own proprietary medication terminology. In either case, the scope of the functionality for EHR systems relates to their ability to allow users to encode medications according to a standard representation.
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Medication Management, Special Terminology and InformationNormative Statementsno
Req-1114Integrate vaccine administration with other systems2013 FormatThe system MAY integrate vaccine dose administration with vaccine/medication management systems and practice management/billing systems.Immunizations, Medication ManagementNormative Statementsno
Req-1115EHR communication with medication management system2013 FormatIF vaccines doses are managed by a vaccine/medication management system, THEN the EHR system SHOULD exchange standard messages with the medication management system.Immunizations, Medication ManagementNormative Statementsno
Req-1116Vaccine administration messages to billing system2013 FormatThe system SHOULD send standard messages to the practice management/billing system that include vaccine-specific administration codes.Immunizations, Medication ManagementNormative Statementsno
Req-1232Descriptors for patient weight2013 FormatThe system SHALL support the capture and recording of patient weight including optional descriptors such as Unknown or Estimated.Medication Management, Well Child/Preventive CareNormative Statementsno
Req-1233Multiple units of measurement2013 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.
Medication Management, Well Child/Preventive CareNormative Statementsno
Req-1235Capture medication dosing details2013 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.
Medication ManagementNormative Statementsno
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