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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-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-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-285Administrative and Financial2013 FormatSystem supports Administrative and Financial functions.Children with Special Healthcare Needs, Genetic information, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
Req-486Ability to prompt for frequent monitoring of specific scales and scores2013 FormatThe system SHALL prompt for frequent monitoring of specific scales and scores that have a dynamic nature, including step-wise scales that assess the response to increasingly noxious stimuli to define levels of consciousness.Specialized Scales/ScoringNormative Statementsno
Req-488Incorporate scale and score tools2013 FormatThe system SHOULD incorporate scale and score tools that can often be quickly performed and easily recalled, especially in critical care areas.Specialized Scales/ScoringNormative Statementsno
Req-627User Interface preferences2013 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.
Growth Data, Specialized Scales/ScoringNormative Statementsno
Req-688Encounter/Episode of Care Management2013 Format
STATEMENT: Support the definition of Manage and document the health care needed and delivered during an encounter/episode of care.
DESCRIPTION: Using data standards and technologies that support interoperability, encounter management promotes patient-centered/oriented care and enables...
STATEMENT: Support the definition of Manage and document the health care needed and delivered during an encounter/episode of care.
DESCRIPTION: Using data standards and technologies that support interoperability, encounter management promotes patient-centered/oriented care and enables real time, immediate point of service, point of care by facilitating efficient work flow and operations performance to ensure the integrity of: (1 the health record, (2 public health, financial and administrative reporting, and (3 the healthcare delivery process
This support is necessary for direct care functionality that relies on providing user interaction and workflows, which are configured according to clinical protocols and business rules based on encounter specific values such as care setting, encounter type (inpatient, outpatient, home health, etc. provider type, patient's EHR, health status, demographics, and the initial purpose of the encounter.
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Specialized Scales/ScoringHeaderno
Req-701Encounter Specific Functionality2013 Format
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining...
STATEMENT: Provide assistance in assembling appropriate data, supporting data collection and processing output from a specific encounter.
DESCRIPTION: Workflows, based on the encounter management settings, will assist (with triggers alerts and other means in determining and supporting the appropriate data collection, import, export, extraction, linkages and transformation. As an example, a pediatrician is presented with diagnostic and procedure codes specific to pediatrics. Business rules enable automatic collection of necessary data from the patient's health record and patient registry. As the provider enters data, workflow processes are triggered to populate appropriate transactions and documents. For example, data entry might populate an eligibility verification transaction or query the immunization registry.
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Specialized Scales/ScoringFunctionno
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