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Req-100Geographic locations visited2013 FormatThe system SHOULD record geographic areas visited by the patient for use in cases of vector-borne epidemiology.Well Child/Preventive CareNormative 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-108Support for Health Maintenance: Preventive Care and Wellness2013 FormatSystem supports Preventive Care and Wellness aspects of health maintenance.Activity Clearance, EPSDT, Newborn Screening, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareHeaderno
Req-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, 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.
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EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive CareFunctionno
Req-123Patient, Family and Care Giver Education2013 Format
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in...
Facilitate access to educational or support resources pertinent to, and usable by, the patient or patient representative.
The provider or patient is presented with a library of educational materials. Material may be made available in the language or dialect understood by the patient or representative. Material should be at the level of the patient or representative's level of understanding and sensory capability. Special needs are documented. Material may be disseminated via a mode available to and acceptable by the patient e.g., printed, electronically or otherwise. The review of material between the clinician and the patient, and the patient's understanding of the review, is documented when desired by the clinician. The patient or patient's representatives are able to obtain educational information independently without formal review with the clinician if desired.
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Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-124Support for Identification of Potential Problems and Trends2013 Format
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab...
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab results it is important to be able to identify potential problems and trends that may be patient-specific, given the individual's personal health profile, or changes warranting further assessment. For example: significant trends (lab results, weight a decrease in creatinine clearance for a patient on metformin, an abnormal increase in INR for a patient on warfarin, an increase in suicidal ideation; presence of methamphetamines; or absence of therapeutic levels of antidepressants.
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Well Child/Preventive CareFunctionno
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-129Present Alerts for Preventive Services and Wellness2013 Format
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider...
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider or patient is presented with due or overdue activities based on protocols for preventive care and wellness. Examples include but are not limited to, routine immunizations, adult and well child care, age and gender appropriate screening exams, such as PAP smears. The provider may wish to provide reminders to the patient based on the alert.
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EPSDT, Newborn 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-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-255Manage Clinical Documents and Notes2013 Format
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on...
STATEMENT: Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.
DESCRIPTION: Clinical documents and notes may be unstructured and created in a narrative form, which may be based on a template, graphical, audio, etc.. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation is important and appropriate for different users and situations.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-262Manage Patient-Specific Care and Treatment Plans2013 Format
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the...
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
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Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareFunctionno
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-265Notifications and Reminders for Preventive Services and Wellness2013 Format
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are...
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are due or overdue and these communications can be captured. Examples include but are not limited to time sensitive patient and provider notification of: follow-up appointments, laboratory tests, immunizations or examinations. The notifications can be customized in terms of timing, repetitions and administration reports. E.g. a PAP test reminder might be sent to the patient two months prior to the test being due, repeated at three month intervals, and then reported to the administrator or clinician when nine months overdue.
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EPSDT, Newborn Screening, Patient Portals - PHR, Well Child/Preventive CareFunctionno
Req-266Present Ad Hoc Views of the Health Record2013 Format
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters,...
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
DESCRIPTION: A key feature of an electronic health record is its ability to support the delivery of care by enabling prior information to be found and meaningfully displayed. EHR systems should facilitate search, filtering, summarization, and presentation of available data needed for patient care. Systems should enable views to be customized, for example, specific data may be organized chronologically, by clinical category, or by consultant, depending on need. Jurisdictional laws and organizational policies that prohibit certain users from accessing certain patient information must be supported.
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Immunizations, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareFunctionno
Req-267Produce a Summary Record of Care2013 Format
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of...
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of care. Create service reports at the completion of an episode of care such as, but not limited to, discharge summaries and public health reports, without additional input from clinicians.
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Primary Care Management, 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-269Support for Standard Care Plans, Guidelines, Protocols2013 Format
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and...
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported.
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EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-278Standard Report Generation2013 Format
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making,...
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making, audit trail and metadata reporting, as well as to create reports for patients. Many systems may use internal or external reporting tools to accomplish this (such as Crystal Report
Reports may be based on structured data and/or unstructured text from the patient's health record.
Users need to be able to sort and/or filter reports. For example, the user may wish to view only the diabetic patients on a report listing patients and diagnoses.
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Activity Clearance, Birth Information, EPSDT, Well Child/Preventive CareFunctionno
Req-279Support Clinical Communication2013 Format
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs...
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs of healthcare-related communications, and provides automatic tracking and reporting. The list of communication participants is determined by the care setting and may change over time. Because of concerns about scalability of the specification over time, communication participants for all care settings or across care settings are not enumerated here because it would limit the possibilities available to each care setting and implementation. However, communication between providers and between patients and providers will be supported in all appropriate care settings and across care settings. Implementation of the EHRS enables new and more effective channels of communication, significantly improving efficiency and patient care. The communication functions of the EHRS will eventually change the way participants collaborate and distribute the work of patient care.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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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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Req-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, Well Child/Preventive CareHeaderno
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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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-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-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-290Support for Condition Based Care and Treatment Plans, Guidelines, Protocols2013 FormatSystem supports Condition Based Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-291Care and Treatment Plans, Guidelines and Protocols2013 FormatSystem maintains Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
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.
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Growth Data, Prenatal Screening, Well Child/Preventive CareHeaderno
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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Headerno
Req-429Screening tool status2013 FormatThe system SHALL capture the administration, completion, and evaluation of screening tools.Well Child/Preventive CareNormative Statementsno
Req-434Targeted patient education materials after screening2013 FormatThe system SHOULD provide access to targeted patient education materials when screening triggers specialist or early-intervention program referral.Well Child/Preventive CareNormative Statementsno
Req-455Sport/Activity Clearances2013 Format
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should...
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should not be confused with a well-child physical examination conducted for the purpose of establishing a patient's health status nor should it be confused with the inpatient examination, assessment, or history and physical. Elements of the Activity Clearance may be specific to the requesting entity (e.g. a school district or the requesting entity may provide a specific form for the clinician to report his or her findings. Alternate names for these types of examinations include: Sports Qualifying Examinations, Clearance forms, and Pre-participation screens.
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Activity Clearance, Well Child/Preventive CareHeaderno
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-513Retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the victim, teen pregnancy and births.2013 FormatIn cases of child abuse the system SHOULD provide the ability to retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the patient, teen pregnancy and births.Child Abuse Reporting, Well Child/Preventive CareNormative Statementsno
Req-515Ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance.Child Abuse Reporting, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-561Patient Knowledge Access2013 Format
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable...
STATEMENT: Provide the ability to access reliable information about wellness, disease management, treatments, peer support groups and related information that is relevant for a specific patient.
DESCRIPTION: An individual will be able to find reliable information to research a health question, follow up from a clinical visit, identify treatment options, or other health information needs. The information may be linked directly from entries in the health record, or may be accessed through other means such as key word search. The information may be provided as part of the EHR system but may also include patient information from external databases or specific websites.
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Well Child/Preventive CareFunctionno
Req-562Support for Knowledge Access2013 FormatSystem supports Knowledge Access.Well Child/Preventive CareHeaderno
Req-563Clinical Task Assignment and Routing2013 Format
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom...
STATEMENT: Assignment, delegation and/or transmission of tasks to the appropriate parties.
DESCRIPTION: Tasks are at all times assigned to at least one user or role for disposition. Whether the task is assignable and to whom the task can be assigned will be determined by the specific needs of practitioners in a care setting. Task-assignment lists help users prioritize and complete assigned tasks. For example, after receiving communication (e.g. a phone call or e-mail from a patient, the triage nurse routes or assigns a task to return the patient's call to the physician who is on call. Task creation and assignment may be automated, where appropriate. An example of a system-triggered task is when lab results are received electronically; a task to review the result is automatically generated and assigned to a clinician. Task assignment ensures that all tasks are disposed of by the appropriate person or role and allows efficient interaction of entities in the care process.
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Well Child/Preventive CareFunctionno
Req-564Support for Referral Process2013 Format
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof...
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof are presented to the provider. Standardized or evidence based protocols for appropriate workup prior to referral may be presented.
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Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-565Orders, Referrals, Results and Care Management2013 FormatSystem supports Orders, Referrals, Results and Care Management.Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareHeaderno
Req-568Manage Referrals2013 Format
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking...
STATEMENT: Enable the origination, documentation and tracking of referrals between care providers or healthcare organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.
DESCRIPTION: Documentation and tracking of a referral from one care provider to another is supported, whether the referred to or referring providers are internal or external to the healthcare organization. Guidelines for whether a particular referral for a particular patient is appropriate in a clinical context and with regard to administrative factors such as insurance may be provided to the care provider at the time the referral is created.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-569Support for Non-Medication Ordering2013 Format
STATEMENT: Display and request provider validation of information necessary for non-medication orders that make the order pertinent, relevant and resource-conservative at the time of provider order entry.

DESCRIPTION: Possible order entry support includes, but...
STATEMENT: Display and request provider validation of information necessary for non-medication orders that make the order pertinent, relevant and resource-conservative at the time of provider order entry.

DESCRIPTION: Possible order entry support includes, but is not limited to: notification of missing results required for the order, suggested corollary orders, notification of duplicate orders, institution-specific order guidelines, guideline-based orders/order sets, order sets, order reference text, patient diagnosis specific recommendations pertaining to the order. Also, warnings for orders that may be inappropriate or contraindicated for specific patients (e.g. X-rays for pregnant women are presented.

Non-medication orders include orders such as:
• supplies such as 4x4's and ACE bandages
• non-medical devices such as TTY phones for the hearing impaired
• groups of supplies or kits common to an organization
• simple durable medical equipment (DME such as crutches or walkers
• complex DME such as wheelchairs and hospital beds
• therapies and other services that may require a referral and/or an authorization for insurance coverage
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Primary Care Management, Well Child/Preventive CareFunctionno
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