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Req-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
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-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-128Manage Patient Demographics2013 Format
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth,...
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, time of birth, gestation, gender, and other information is stored and maintained for unique patient identification, reporting purposes and for the provision of care. Patient demographics are captured and maintained as discrete fields (e.g., patient names and addresses and may be enumerated, numeric or codified. Key patient identifiers are shown on all patient information output (such as name and ID# on each screen of a patient's record The system will track who updates demographic information, and when the demographic information is updated.
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Birth Information, Child Welfare, Genetic information, Growth Data, Patient Identifier, Prenatal Screening, Well Child/Preventive CareFunctionno
Req-249Health Record Output2013 Format
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare...
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare process, supports selection of specific sections of the health record, and allows healthcare organizations to define the report and/or documents that will comprise the formal health record for disclosure purposes. A mechanism should be provided for both chronological and specified record element output. This may include defined reporting groups (i.e. print sets For example: Print Set A = Patient Demographics, History & Physical, Consultation Reports, and Discharge Summaries. Print Set B = all information created by one caregiver. Print Set C = all information from a specified encounter. An auditable record of these requests and associated exports may be maintained by the system. This record could be implemented in any way that would allow the who, what, why and when of a request and export to be recoverable for review. The system has the capability of providing a report or accounting of disclosures by patient that meets in accordance with scope of practice, organizational policy and jurisdictional law.
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Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, 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-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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Functionno
Req-274Patient Privacy and Confidentiality2013 Format
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of...
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of EHRs are violated if access to EHRs occurs without authorization. Violations or potential violations can impose tangible economic or social losses on affected patients, as well as less tangible feelings of vulnerability and pain. Fear of potential violations discourages patients from revealing sensitive personal information that may be relevant to diagnostic and treatment services. Rules for the protection of privacy and confidentiality may vary depending upon the vulnerability of patients and the sensitivity of records. Strongest protections should apply to the records of minors and the records of patients with stigmatized conditions. Authorization to access the most sensitive parts of an EHR is most definitive if made by the explicit and specific consent of the patient. Please see the definition of masking in the glossary.
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Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
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-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-553Assign parts of the EHR to another patient identifier2013 FormatThe system SHOULD provide the ability to assign parts of the electronic health record to another patient identifier and delete them permanently from the former according to organizational policy or jurisdictional law relating to protections of birth records of adoptees.Patient Identifier, Security and ConfidentialityNormative Statementsno
Req-674Patient indicators on reports2013 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.
Patient IdentifierNormative Statementsno
Req-895Birth History2013 FormatBirth represents a significant milestone. Newborn babies undergo large physiologic changes that make them susceptible to medical problems in the perinatal period. An accurate birth history provides the foundation for good newborn and child health care.Birth Information, Patient Identifier, Specialized Scales/ScoringHeaderno
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
Req-901Capture and record Birth Order for Multiple Births2013 FormatIf an infant is not a singleton, the system SHALL record the birth order.Birth Information, Patient IdentifierNormative Statementsno
Req-989Birth Demographics2013 FormatIn either single or multiple births the mother's demographics, except for name, are associated with the child. Additionally, the names initially given the baby(ies may be simply "Baby 1," "Baby 2," etc.Patient IdentifierHeaderno
Req-990Unique newborn identifiers2013 FormatThe system SHALL generate a unique identifier for each newborn.Patient IdentifierNormative Statementsno
Req-991Temporary newborn names2013 FormatThe system SHALL be able to record temporary names such as "Baby 1" to "Baby N".Patient IdentifierNormative Statementsno
Req-992Associate mother’s demographics with newborn2013 FormatThe system SHALL provide the ability to associate elements of the mother's demographic information, aside from name and other personal identifiers, with each baby in the single or multiple birth situation.
Example: Street address, telephone number, email address but NOT mother's date of birth, driver's license, etc.
Patient IdentifierNormative Statementsno
Req-993Updates to temporary names/demographics2013 FormatThe system SHALL enable updates to demographic information such as replacing the temporary names "Baby 1" to "Baby N" with the actual names, as well as other demographic information, when available.

See Req-992 for demographic information examples.
Patient IdentifierNormative Statementsno
Req-1007Copy and paste selected information from another medical record/chart2013 Format
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL...
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL support suppression of the maternal identity in cases that require parental confidentiality (e.g. voluntary surrender for adoption, or removal from the mother's care for other reasons
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Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
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
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