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 1-50 of 53
remove Filtering Topic Area on Specialized Scales/Scoring
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-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-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-627User Interface preferences2013 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.
Growth Data, Specialized Scales/ScoringNormative Statementsno
Req-94110 minute Apgar2013 FormatThe system SHALL record Apgar score at 10 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-9405 minute Apgar2013 FormatThe system SHALL record Apgar score at 5 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-942Continuing Apgar scores2013 FormatThe system MAY record Apgar score at every 5 minutes after 10 minutes if the total score is less than; 5 (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-9391 minute Apgar2013 FormatThe system SHALL record Apgar score at 1 minute (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-1018Support Apgar scores2013 FormatThe system SHALL support Apgar scores.Specialized Scales/ScoringNormative Statementsno
Req-1019Gestational age estimation2013 FormatThe system SHALL support gestational age estimation based on Ballard Exam or Dubowitz score.Specialized Scales/ScoringNormative Statementsno
Req-1020Finnegan Neonatal Abstinence Scoring (NAS)2013 FormatThe system SHALL support modified Finnegan Neonatal Abstinence Scoring (NASSpecialized Scales/ScoringNormative Statementsno
Req-1021N-PASS Neonatal Pain Scale2013 FormatThe system SHALL support the N-PASS Neonatal Pain Scale.Specialized Scales/ScoringNormative Statementsno
Req-1022Sarnat scores2013 FormatThe system SHALL support Sarnat scores for hypoxic ischemic encephalopathy.Specialized Scales/ScoringNormative Statementsno
Req-1023Intra-ventricular hemorrhage scoring2013 FormatThe system SHALL support intra-ventricular hemorrhage scoring.Specialized Scales/ScoringNormative Statementsno
Req-1032Asthma Severity Scoring2013 FormatThe system SHALL support Asthma Severity Scoring.Specialized Scales/ScoringNormative Statementsno
Req-1033Broselow Tape color codes2013 FormatThe system SHALL be able to both record Broselow Tape color codes and translate them into corresponding size / dose categories.Specialized Scales/ScoringNormative Statementsno
Req-1034Pediatric Glasgow Coma Scale2013 Format
The system SHALL support the Pediatric Glasgow Coma Scale.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James...
The system SHALL support the Pediatric Glasgow Coma Scale.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018, 1984.
Show Full Text
Specialized Scales/ScoringNormative Statementsno
Req-1035PRISM III Pediatric Risk of Mortality Score2013 FormatThe system SHALL support the PRISM III Pediatric Risk of Mortality Score.Specialized Scales/ScoringNormative Statementsno
Req-1036Gell-Coombs Classification of Hypersensitivity Disorders2013 FormatThe system SHALL support the Gell-Coombs Classification of Hypersensitivity Disorders.Specialized Scales/ScoringNormative Statementsno
Req-1037Wong-Baker FACES pain scale2013 FormatThe system SHALL support the Wong-Baker FACES pain scale.Specialized Scales/ScoringNormative Statementsno
Req-1038Salter-Harris classification of physeal injuries2013 FormatThe system SHALL support the Salter-Harris classification of physeal injuries.Specialized Scales/ScoringNormative Statementsno
Req-1039Tanner stages of adolescent development2013 FormatThe system SHALL support the Tanner stages of adolescent development.Specialized Scales/ScoringNormative Statementsno
Req-1024Modified Bell Staging Criteria2013 FormatThe system SHALL support the Modified Bell Staging Criteria for necrotizing enterocolitis.Specialized Scales/ScoringNormative Statementsno
Req-1025International classification of retinopathy of prematurity (ICROP)2013 FormatThe system SHALL support the international classification of retinopathy of prematurity (ICROPSpecialized Scales/ScoringNormative Statementsno
Req-1026Modified Glasgow Coma Scale2013 Format
The system SHALL support the Modified Glasgow Coma Scale for infants.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins,...
The system SHALL support the Modified Glasgow Coma Scale for infants.
REF: Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018, 1984.
Show Full Text
Specialized Scales/ScoringNormative Statementsno
Req-1027INFINIB developmental score2013 FormatThe system SHALL support the infant neurological international battery (INFINIB developmental score.Specialized Scales/ScoringNormative Statementsno
Req-1028Breast feeding / breast milk drug compatibility categories2013 FormatThe system SHALL support breast feeding / breast milk drug compatibility categories (1= Compatible, 2=Use With Caution, 3=Unknown with Concerns, X=Contraindicated, ?=Safety not EstablishedSpecialized Scales/ScoringNormative Statementsno
Req-1029Pregnancy drug compatibility categories2013 FormatThe system SHALL support pregnancy drug compatibility categories (A, B, C, D, XSpecialized Scales/ScoringNormative Statementsno
Req-1031International Classification for (VUR)2013 FormatThe system SHALL support the International Classification for Vesico-ureteral Reflux (VUR - Grades 1-5.Specialized Scales/ScoringNormative Statementsno
Req-1049Maxfield-Buchholz Social Maturity Scale2013 FormatThe system SHALL support the Maxfield-Buchholz Social Maturity Scale for Blind Pre-school children.Specialized Scales/ScoringNormative Statementsno
Req-1048Reynell-Zinkin Scales2013 FormatThe system SHALL support the Reynell-Zinkin Developmental Scales.Specialized Scales/ScoringNormative Statementsno
Req-1051Draw-a-Person test2013 FormatThe system SHOULD support The Draw-a-Person test (DAP-Goodenough-Harris Drawing TestSpecialized Scales/ScoringNormative Statementsno
Req-1050Denver Developmental Screening Test2013 FormatThe system SHOULD support The Denver Developmental Screening Test.Specialized Scales/ScoringNormative Statementsno
Req-1041PEDS screen2013 FormatThe system SHALL support the PEDS screen.Specialized Scales/ScoringNormative Statementsno
Req-1043Bayley Scales of Infant Development2013 FormatThe system SHALL support the Bayley Scales of Infant Development.Specialized Scales/ScoringNormative Statementsno
Req-1042Child Autism Rating Scale (CARS)2013 FormatThe system SHALL support the Child Autism Rating Scale (CARSSpecialized Scales/ScoringNormative Statementsno
Req-1045Stanford-Binet Intelligence Scale2013 FormatThe system SHALL support the Stanford-Binet Intelligence Scale.
REF: Binet, Alfred; Simon, Th. (1916 The development of intelligence in children: The Binet-Simon Scale. Publications of the Training School at Vineland New Jersey Department of Research No. 11. E. S. Kite (Trans. Baltimore: Williams & Wilkins. Retrieved 18 July 2010.
Specialized Scales/ScoringNormative Statementsno
Req-1044Conners Comprehensive Behavior Rating Scales2013 FormatThe system SHALL support the Conners Comprehensive Behavior Rating Scales (Conners CBRS™Specialized Scales/ScoringNormative Statementsno
Req-1047Gesell Developmental schedules2013 FormatThe system SHALL support the Gesell Developmental schedules.Specialized Scales/ScoringNormative Statementsno
Req-1046Leiter International Performance scale2013 FormatThe system SHALL support the Leiter International Performance Scale.Specialized Scales/ScoringNormative Statementsno
Req-2043Scales and Scoring2015 Priority ListThe system shall allow the capture of data using an established instrument, the creation of reports and displays using the data, and data use in clinical decision support and in the EHR as necessary.Specialized Scales/ScoringNormative Statementyes
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-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
Show Full Text
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-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.
Show Full Text
Specialized Scales/ScoringHeaderno
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-1016Scales and Scoring2013 FormatMedical care of children relies on a myriad of specialized scales and scoring systems.Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
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.
Show Full Text
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.
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-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.
Show Full Text
Specialized Scales/ScoringFunctionno
Req-938Initial Infant Data2013 FormatData recorded in the first hour of life will guide care in the initial neonatal period.Birth Information, Specialized Scales/ScoringFunctionno
Scroll To Top