United States Health Information Knowledgebase

 

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.

Results 1-26 of 26
remove Filtering Topic Area on Prenatal Screening
MS Excel
Download as an MS Excel spreadsheet.
[Download Excel ReaderExit Disclaimer]
PDF
Download as a PDF file.
[Download PDF ReaderExit Disclaimer]
MS Word
Download as an MS Word document.
[Download Word ReaderExit Disclaimer]
Remove All Filters

sort Req ID
sort Title
sort Release Package
Release Package(s) Selected
sort Description
sort Topic Area
Topic Area(s) Selected
sort Type
Type(s) Selected
sort Critical/Core
Critical/Core(s) Selected
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
Show Full Text
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
Show Full Text
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.
Show Full Text
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
Show Full Text
Headerno
Req-107Standards Based Interoperability2013 Format
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified...
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified view of the system where the reality is that several disparate systems may be coming together.
Interoperability standards also enable the sharing of information between EHR systems, including the participation in regional, national, or international information exchanges.
Timely and efficient access to information and capture of information is promoted with minimal impact to the user.
Show Full Text
Immunizations, Prenatal Screening, Registry Linkages, School-Based LinkagesHeaderno
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.
Show Full Text
Birth Information, Child Welfare, Genetic information, Growth Data, Patient Identifier, Prenatal Screening, 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.
Show Full Text
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
Show Full Text
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.
Show Full Text
Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
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.
Show Full Text
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
Show Full Text
Headerno
Req-295Health Record Information and Management2013 Format
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to...
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to clinical documents. Ensure that information entered by or on behalf of the patient is accurately represented.
DESCRIPTION: Since EHR information will typically be available on a variety of EHR-S applications, an EHR-S must provide the ability to access, manage and verify accuracy and completeness of EHR information, maintain the integrity and reliability of the data, and provide the ability to audit the use of and access to EHR information.
Show Full Text
Growth Data, Prenatal Screening, Well Child/Preventive CareHeaderno
Req-582Indicate unknown patient gender2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-583Compute post conceptional age2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Birth Information, Growth Data, Prenatal ScreeningNormative 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
Show Full Text
Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-1149Legal constraints on importing maternal data2013 FormatThe system SHALL follow applicable state or federal privacy laws regarding the importation of maternal information into the child's record.Prenatal ScreeningNormative Statementsno
Req-1150Electronically import maternal data into patient history2013 FormatWhen electronic access to the mother's data is possible, the system SHALL enable incorporation of selected maternal prenatal and perinatal data into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1151Manually import maternal data into patient history2013 FormatWhen electronic access to the mother's data is not possible, the system SHOULD enable incorporation of selected maternal prenatal and perinatal data by manual entry into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1152Electronically import maternal data from multiple sources2013 FormatWhen the maternal prenatal and perinatal record is split across more than one system (e.g. prenatal care and Labor & Delivery and if electronic access is possible, the system SHOULD enable incorporation of maternal information from each of those systems into the child's record.Prenatal ScreeningNormative Statementsno
Req-1153Distinguish maternal from child data2013 FormatWithin the child's record the system SHALL clearly distinguish maternal history data from directly collected child data.Prenatal ScreeningNormative Statementsno
Req-1154Maternal Group B strep status2013 FormatThe system SHALL capture maternal Group B strep status and prophylaxis according to current guidelines from the CDC into the child's chart.Prenatal ScreeningNormative Statementsno
Req-1155Maternal infections that impact the newborn2013 FormatThe system SHALL capture other maternal infections that can affect the newborn in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative Statementsno
Req-1156Maternal blood type2013 FormatThe system SHALL capture maternal blood type including Rh factor in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative Statementsno
Req-1157Capture maternal problem list2013 FormatThe system SHALL enable selective capture into the child's chart of the maternal problem list by the child's healthcare provider.Prenatal ScreeningNormative Statementsno
Req-1158Preserve codification of maternal data2013 FormatMaternal data, when captured into the child's chart, SHOULD preserve codification when codified in the maternal chart.Prenatal ScreeningNormative Statementsno
Req-1159Prenatal ultrasound results2013 FormatThe system SHALL capture into the child's chart any specific condition diagnosed by prenatal ultrasound in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1160Prenatal testing results2013 FormatThe system SHALL capture into the child's chart results of maternal testing for conditions in the newborn (e.g., the "quad screen" or "triple screen" in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1161Prenatal in utero testing results2013 FormatThe system SHALL capture into the child's chart results of any specific condition diagnosed by in utero testing (e.g., amniocentesis in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1162Capture data that precedes the newborn’s record2013 FormatThe system SHALL allow capture of data that were collected for a newborn before the newborn's electronic record was created.Prenatal ScreeningNormative Statementsyes
Req-2009Allow unknown patient sex2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Genetic information, Birth Information, Prenatal ScreeningNormative Statementyes
Scroll To Top