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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-104Data and Documentation From External Sources2013 FormatExternal sources are those outside the EHR system, including clinical, administrative, and financial information systems, other EHR systems, PHR systems, and data received through health information exchange networks.Birth Information, Parents and Guardians and Family Relationship Data, Patient Portals - PHRHeaderno
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.
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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
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Req-248Capture Patient Health Data Derived from Administrative and Financial Data and Documentation2013 Format
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data...
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data derived from administrative or financial data from clinically authenticated data. Sources of administrative and financial data relating to a patient's health may provide this data for entry into the health record or be given a mechanism for entering this data directly. The data must be explicitly labeled as derived from administrative or financial data, and information about the source must be linked with that data. Patient health data that is derived from administrative or financial data may be provided by:
1. the patient
2. a provider
3. a payer, or
4. entities that transmit or process administrative or financial data.
Since this data is non-clinical, it may not be authenticated for inclusion in the patient's legal health record. Registration data, which may contain demographic data and pertinent positive and negative histories, is an example of administrative and financial data that may be captured.
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Parents and Guardians and Family Relationship DataFunctionno
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-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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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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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-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.
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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
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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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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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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.
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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
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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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Req-489Support interoperability between various systems2013 FormatThe system MAY be interoperable between the juvenile justice system, medical facilities, probation department, schools, and each state's human services agency.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-506Capture both presence and absence of conditions in history2013 FormatThe system SHALL provide the ability to capture patient history as both a presence and absence of conditions, i.e., the specification of the absence of a personal or family history of a specific diagnosis, procedure or health risk behavior.Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementsno
Req-507Import / export data with Surgeon General’s Family Health History Tool2013 Format
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7...
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7 v3 clinical genomics model with data mapping to the family history section of the HITSP C83 CCD content module for family history.
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Genetic information, Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-556Document authority for consent on behalf of minors2013 FormatThe system SHALL allow for documentation of authority of foster parents or custodians to give consent on behalf of a minor patient, including unlimited number of different foster parents or custodians.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-557Document time restrictions on authority for consent on behalf of patient2013 FormatThe system SHALL provide the ability to document any time restrictions on the patient's guardian, foster parent or custodian's level of authority to make decisions on behalf of the patient.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-578Locate records based on previous names2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-584Amend administrative or financial 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-669Sibling data sharing2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-679Identify and Maintain a Patient Record2013 Format
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and...
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and linked to the patient record. Static data elements as well as data elements that will change over time are maintained. The patient is uniquely identified, after which the record is tied to that patient. Combining information on the same patient, or separating information where it was inadvertently captured for the wrong patient, helps maintain health information for a single patient. In the process of creating a patient record, it is at times advantageous to replicate identical information across multiple records, so that such data does not have to be re-entered. For example, when a parent registers children as new patients, the address, guarantor, and insurance data may be propagated in the children's records without having to re-enter them.
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Parents and Guardians and Family Relationship DataFunctionno
Req-683Healthcare Resource Availability2013 Format
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In...
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In times of identified local or national emergencies and upon request from authorized bodies, provide current status of healthcare resources including, but not limited to, available beds, providers, support personnel, ancillary care areas and devices, operating theaters, medical supplies, vaccines, and pharmaceuticals. The intent is to enable the authorized body to distribute or re-distribute either resources or patient load to maximize efficient healthcare delivery. In addition, these functions may also be used for internal assessment and planning purposes by facility administrators
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Parents and Guardians and Family Relationship DataFunctionno
Req-684Propagate identical data for related patients2013 FormatIF related patients register with any identical data, THEN the system SHOULD provide the ability to propagate that data to all their records.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-702Secure Data Routing2013 Format
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the...
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the entities (applications, institutions, directories it expects. This function depends on entity authorization and authentication to be available in the system. For example, a physician practice management application in an EHR-S might send claim attachment information to an external entity. To accomplish this, the application must use a secure routing method, which ensures that both the sender and receiving sides are authorized to engage in the information exchange. Known sources and destinations can be established in a static setup or they can be dynamically determined. Examples of a static setup are recordings of IP addresses or recordings of DNS names. For dynamic determination of known sources and destinations systems can use authentication mechanisms as described in Req-759 (HL7 ID: IN.1.1 For example, the sending of a lab order from the EHRS to a lab system within the same organization usually uses a simple static setup for routing. In contrast sending a lab order to a reference lab outside of the organization will involve some kind of authentication process.
In general, when the underlying network infrastructure is secure (e.g. secure LAN or VPN the simple static setup is used.
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Parents and Guardians and Family Relationship DataFunctionno
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.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
Req-1074Capture patient relationships2013 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.
Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsyes
Req-1182Store and retrieve restraining and visitation order information2013 FormatThe system SHALL provide the ability to access, store, and retrieve any restraining orders, visitation orders and the person or organization with decision making authority within the native EHR system.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1183Access restraining and visitation order information from external source2013 FormatThe system MAY provide the ability to access, store, and retrieve from an external information source (e.g. registry any restraining or visitation orders, and the person or organization with decision making authority.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1192Family history relationships2013 Format
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents...
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.
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Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1199Family and patient history of substance abuse2013 FormatThe system SHOULD have access to history of drug or alcohol abuse of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1200Family and patient history of intimate partner violence2013 FormatThe system SHOULD have access to history of intimate partner violence of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1201Family and patient history of suicidal ideation or depression2013 FormatThe system SHOULD have access to history of suicidal ideation or depression of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1202Definition of Terms for Parents and Guardians and Family Relationship Data2013 Format
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person...
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person with durable power of attorney for health care for a patient, the executor or administrator of the patient's estate, or the person responsible for the patient's estate if it is not to be probated.
Guarantor: The guarantor is the person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patients 18 years of age and younger.
Medical Decision Maker: the authority who has the ability to make decisions related to the medical care for a youth. Decision authority may be full or limited, with limited typically allowing consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR. For children in group or residential treatment this is the court or child welfare staff.
Full medical decision making authority: Full authority to make medical decisions (such as consent to treatment and procedures on behalf of the minor. Full medical decision making is typically afforded to parents and in the case of foster children to the state social services agency (via a case worker typically
Limited medical decision making authority: Less than full authority for medical decision making; typically limited decision making (as applies to most foster parent situations allows consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR.
Biological Parent: birthparents or natural parents, the man and woman who conceive a child; also known as genetic parents.
Foster Parent: An adult who takes over care of a minor child who has been placed in the foster care system because the child's own family cannot take care of the child or have had custody taken away by a court or agency. (*Foster parent subcategories and definitions of guardianship may vary from state to state.
Adoptive Parent: A person who completes all the requirements to legally adopt a child who is not his or her biological child.
Surrogate Parent: a woman who agrees to be impregnated by a sperm donor and to carry the child to term, at which time the offspring is surrendered to the care of another.
Custodial Parent: the parent who has physical and/or legal custody of his/her child by court order.
Noncustodial Parent: a parent who does not have physical and/or legal custody of his/her child by court order.
Parental rights: The legal rights and corresponding legal obligations that go along with being the parent of a child.
Legal Guardian: An adult to whom the court has given parental responsibility and authority for a child. Appointment as guardian requires the filing of a petition and approval by the court and can be done without terminating the parental rights of the child's parents. Guardian rights vary by state and sometimes by county. A guardian may or may be the medical consenter. Typically, a guardian may be able to give consent for routine medical care and minor surgical procedures, but not for end-of-life decisions such as DNR (Do Not Resuscitate
Guardian of the Estate: Someone who looks after a child's property.
Guardian of the Person: An adult who has legal authority to make personal decisions for the child, including responsibility for his physical, medical, and educational needs. The medical decision making authority of guardian may be limited.
Full Sibling: is a sibling with whom an individual shares the same biological parents.
Half Sibling (half brother or half sister is a sibling with one shared biological parent.
Agnate Sibling: a half-sibling that shares the same father (but different mothers
Uterine Sibling: a half-sibling that shares the same mother (but different fathers
Case worker: is a person that provides social services and assistance to improve the social and psychological functioning of children and their families and to maximize the family well-being and the academic functioning of children. May assist parents, arrange adoptions, and find foster homes for abandoned or abused children. In schools, they address such problems as teenage pregnancy, misbehavior, and truancy. A job as a Child Welfare Caseworker falls under the broader career category of Child, Family, and School Social Workers. Case workers may work for a governmental or private agency.
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Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1203Navigate between family member charts2013 FormatThe system SHOULD provide a feature to navigate easily between related charts of biological family members (such as mother/baby, parent/child, and siblings without dependence on matching surnames.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1204Import/export family member medical data2013 FormatThe system MAY offer a utility to copy or import and export common medical information, such as family history information, from medical records of biological family members.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1205Import/export family member demographics2013 FormatThe system SHOULD offer a utility to copy or import and export demographic information between records of parents, guardians, and siblings (including foster siblings within the same home.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1206Authenticated external access to chart2013 FormatThe system MAY facilitate the ability to search and retrieve certain patient records for an appropriately authenticated external party that requires access to a child's health information.Parents and Guardians and Family Relationship DataNormative 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-1209Family member affiliations2013 FormatThe system MAY have access to parents, guardians, siblings and patients' affiliation with religious organizations, community organizations, gangs, etc.Parents and Guardians and Family Relationship DataNormative 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-1213Distinguish guardian from guarantor2013 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.
Parents and Guardians and Family Relationship DataNormative 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-2006Ability to access family history, including all guardians and caregivers2015 Priority ListThe system shall provide the ability to record information about all guardians and caregivers (biological parents, foster parents, adoptive parents, guardians, surrogates, and custodians siblings, and case workers; with contact information for each.Child Abuse Reporting, Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementyes
Req-2008Ability to document parental (guardian) notification or permission2015 Priority ListThe system shall provide the ability to document parental (guardian notification or permission for consenting minors to receive some treatments as required by institutional policy or jurisdictional law.Security and Confidentiality, Parents and Guardians and Family Relationship DataNormative Statementyes
Req-2021Associate mother's demographics with newborn2015 Priority ListThe system shall provide the ability to associate multiple identifying parent or guardian demographic information, such as relationship to child, street address, telephone number, and/or email address for each individual child.Patient Identifier, Parents and Guardians and Family Relationship DataNormative Statementyes
Req-2038Separate consent, assent and permission2015 Priority ListThe system shall support the recording of consent, assent, and permission as separate artifacts.Security and Confidentiality, Parents and Guardians and Family Relationship DataNormative Statementyes
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