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.

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]

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-457Support the capture of coded pediatric functional health status measures2013 FormatThe system SHALL support the capture of coded pediatric functional health status measures (e.g. ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-456Support the capture of coded age based, disease specific measures2013 FormatThe system SHALL support the capture of coded age based, disease specific measures used in the characterization and/or categorization of disease severity (e.g. Asthma: National Heart Lung and Blood Institute Asthma Severity Tool; depression; ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-461Support the addition or exclusion of patients from registries by authorized users2013 FormatThe system SHOULD support the addition or exclusion of patients from registries by authorized users and capture addition or exclusion criteria.Children with Special Healthcare NeedsNormative Statementsno
Req-1006Support prescription details2013 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.
Medication ManagementNormative Statementsno
Req-858Support precise measurement units in both metric and English system2013 FormatThe system SHALL have similar levels of precision in both the Metric and English systems for recording weight.Growth DataNormative Statementsno
Req-2023Support pre-visit history/screening/prevention forms2015 Priority ListThe system shall record values for pediatric specific pre-visit parent/patient reported data in a manner that enables retrieval and reporting.Well Child/Preventive CareNormative Statementyes
Req-550Support patient consent requirements based on law2013 FormatThe system SHOULD determine the need for minor patient consent based on determination of age of majority based on jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-1091Support organizational configuration for well and preventive care alerts and reports2013 FormatThe system SHOULD support age-specific organizational configuration of rules, links, and content for well and preventive care alerts and reports.Well Child/Preventive CareNormative Statementsno
Req-489Support interoperability between various systems2013 FormatThe system MAY be interoperable between the juvenile justice system, medical facilities, probation department, schools, and each state's human services agency.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1067Support incremental interoperability standards2013 FormatThe system SHOULD support incremental interoperability standards between EHRs and school management systems, health service providers, and governmental agencies.Children with Special Healthcare NeedsNormative Statementsno
Req-2042Support growth charts for children2015 Priority List
The system shall support display of growth charts that plot selected growth parameters such as height, weight, head circumference, and BMI (entered with appropriate precision or computed as described in Req-2019...
The system shall support display of growth charts that plot selected growth parameters such as height, weight, head circumference, and BMI (entered with appropriate precision or computed as described in Req-2019 along with appropriate sets of norms provided by the CDC or in a compatible tabular format (typically based on Lambda-Mu-Sigma [LMS] curve fitting computational method
Show Full Text
Growth DataNormative Statementyes
Req-724Support for population, maintenance, and export of registries2013 FormatThe system SHOULD support the population, maintenance, and export of registries including patients with significant anthropometric findings and related disease risk factors.Growth DataNormative Statementsno
Req-725Support for population level reporting2013 FormatThe system SHOULD support population level reporting of collected and derived measures of growth and body composition and related clinical and demographic information.Growth DataNormative Statementsno
Req-1124Support for ordering immunizations2013 FormatSupport for ordering immunizationsImmunizationsFunctionno
Req-1117Support for immunization information output management2013 FormatSupport for immunization information output managementImmunizations, Well Child/Preventive CareFunctionno
Req-118Support for growth data assessment and planning2013 FormatThe system SHOULD provide access to display and print accepted anthropometry procedure standards/training; provider/layperson growth chart interpretation guides; and related disease management guidelines.Growth DataNormative Statementsno
Req-660Support for age-appropriate referrals2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
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.
Show Full Text
EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-682Support for Result Interpretation2013 Format
STATEMENT: Evaluate results and notify provider of results within the context of the patient's healthcare data.
DESCRIPTION: Possible result interpretations include, but are not limited to: abnormal result evaluation/notification, trending of results (such as discrete...
STATEMENT: Evaluate results and notify provider of results within the context of the patient's healthcare data.
DESCRIPTION: Possible result interpretations include, but are not limited to: abnormal result evaluation/notification, trending of results (such as discrete lab values evaluation of pertinent results at the time of provider order entry (such as evaluation of lab results at the time of ordering a radiology exam evaluation of incoming results against active medication orders.
Show Full Text
Primary Care Management, Well Child/Preventive CareFunctionno
Req-271Support for Research Protocols Relative to Individual Patient Care2013 FormatSTATEMENT: Provide support for the management of patients enrolled in research protocols.
DESCRIPTION: The clinician is presented with appropriate protocols for patients participating in research studies, and is supported in the management and tracking of study participants.
Primary Care ManagementFunctionno
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.
Show Full Text
Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-272Support for Patient Specific Dosing and Warnings2013 Format
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g....
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g. pregnancy, breast-feeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, height, weight, and body surface area (BSA shall also be incorporated.
Show Full Text
Immunizations, Medication ManagementFunctionno
Req-693Support for Notification and Response2013 Format
STATEMENT: Upon notification by an external, authoritative source of a health risk within the cared for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.
DESCRIPTION: After receiving a...
STATEMENT: Upon notification by an external, authoritative source of a health risk within the cared for population, alert relevant providers regarding specific potentially at-risk patients with the appropriate level of notification.
DESCRIPTION: After receiving a notice of a health risk within a cared-for population from public health authorities or other external authoritative sources:
1. Identify and notify individual care providers or care managers that a risk has been identified and requires attention; and
2. Provide suggestions on the appropriate course of action.
A care provider now has the ability to decide how patients are notified, if necessary.
For example, this function may be used after detection of a local outbreak of hepatitis A, advising providers of the at-risk population and potential prophylactic treatment.
A second example might be the dissemination of new care guidelines for elderly patients with a specific chronic disease.
Notifications to clinicians or patients may occur by telephone, email, FAX or other methods
Show Full Text
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
Show Full Text
Primary Care Management, Well Child/Preventive CareFunctionno
Req-739Support for Monitoring Response Notifications Regarding a Specific Patient’s Health2013 Format
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that...
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that expected follow-up for a specific patient event (e.g., follow up to error alerts or absence of an expected lab result has not occurred and communicate the omission to appropriate care providers in the chain of authority. The notification process requires a security infrastructure that provides the ability to match a care provider's clinical privileges with the clinical requirements of the notification.
Show Full Text
Children with Special Healthcare NeedsFunctionno
Req-292Support for Medication and Immunization Ordering2013 FormatSystem supports Medication and Immunization Ordering.Immunizations, Medication ManagementHeaderno
Req-273Support for Medication and Immunization Administration2013 Format
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To...
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a by-product of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured.
Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the "window" for timely administration of medications.
Show Full Text
Immunizations, Medication Management, Registry LinkagesFunctionno
Req-703Support for Medication Recommendations2013 Format
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice...
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice standards (e.g. cost or adherence to guidelines a generic brand, a different dosage, a different drug, or no drug (watchful waiting Suggest lab order monitoring as indicated by the medication or the medical condition to be affected by the medication. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etc.
Show Full Text
Medication ManagementFunctionno
Req-562Support for Knowledge Access2013 FormatSystem supports Knowledge Access.Well Child/Preventive CareHeaderno
Req-570Support for Inter-Provider Communication2013 Format
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or...
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or jurisdictional law.
DESCRIPTION: Communication among providers involved in the care process can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room to asynchronous communication (for example, consult reports between physicians Some forms of inter-practitioner communication will be paper based and the EHR-S must be able to produce appropriate documents.
The system should provide for both verbal and written communication. These exchanges would include but not limited to consults, and referrals as well as possible exchanges within the office as part of the provision and administration of patient care (for example, the communication of new information obtained within the office environment during the process of administration of a tetanus shot while the patient is in the exam room
The system should support the creation and acceptance of paper artifacts where appropriate.
Show Full Text
Child Welfare, Primary Care ManagementFunctionno
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.
Show Full Text
Well Child/Preventive CareFunctionno
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-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-745Support for Accurate Specimen Collection2013 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.
Primary Care Management, Well Child/Preventive CareFunctionno
Req-873Support exporting of anthropometric data2013 FormatThe system MAY export anthropometric data to the drug prescribing module to provide additional support.Growth DataNormative Statementsno
Req-846Support display of normative curves in standard deviations2013 FormatFor all curves described here, the system MAY provide views of normative curves in standard deviations to allow for the interpretation of more extreme measurements (e.g., charts for very obese children where all measurements are >95th percentileGrowth DataNormative Statementsno
Req-512Support communication with national, state, and local Child Protective Services, and more2013 FormatThe system MAY communicate with national, state, and local Child Protective Services, law enforcement, care physicians, prosecutor, medical examiner, Medicaid, and Insurance companies.Child Abuse ReportingNormative Statementsno
Req-818Support appropriate newborn screening and follow-up2013 FormatThe system SHALL incorporate the algorithms described in http://pediatrics.aappublications.org/content/121/1/192.abstract Exit Disclaimer to assure screening has been accomplished and that results have been followed up.Newborn ScreeningNormative Statementsno
Req-2018Support appropriate newborn screening and follow-up2015 Priority ListThe system shall incorporate clinical decision support to assure newborn screening has been accomplished and that results have been followed up.Newborn ScreeningNormative Statementyes
Req-833Support adapting of age units per care environment and age threshold needs2013 FormatThe system SHALL enable age units to be adapted to care environment-specific age thresholds.Well Child/Preventive CareNormative Statementsno
Req-546Support ability to export data for non-interfaced registries2013 FormatThe system SHALL provide user controlled export features such as protected text or data files for registries that can't or won't accept interfaced or service fed data.Registry LinkagesNormative Statementsno
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.
Show Full Text
Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-1018Support Apgar scores2013 FormatThe system SHALL support Apgar scores.Specialized Scales/ScoringNormative Statementsno
Req-987Summary forms for non-clinicians2013 FormatThe system SHOULD provide a summary of immunizations, screenings, measurements, physical exam findings, problems, medications, allergies via paper (e.g. "School/Camp Form" or other mechanism (e.g. electronically to non-clinical resources in need of clinical information regarding the child.Well Child/Preventive CareNormative Statementsno
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
Show Full Text
Headerno
Req-1072Structured information from screening tool2013 FormatThe system SHOULD capture information from the screening tool in a structured form.Well Child/Preventive CareNormative Statementsno
Req-1103Store codified newborn screening results2013 FormatThe system SHALL be able to store standardized codified newborn screening results to the degree to which they are made available.Newborn ScreeningNormative Statementsno
Req-1182Store and retrieve restraining and visitation order information2013 FormatThe system SHALL provide the ability to access, store, and retrieve any restraining orders, visitation orders and the person or organization with decision making authority within the native EHR system.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-765Store and Manage Health Record Information2013 Format
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified...
STATEMENT: Store and manage health record information as structured and unstructured data.

DESCRIPTION: Unstructured health record information is information that is not divided into discrete fields AND not represented as numeric, enumerated or codified data.

General examples of unstructured health record information include:
- text
- word processing document
- image
- multimedia

Specific examples include:
- text message to physician
- patient photo
- letter from family
- scanned image of insurance card
- dictated report (voice recording

Structured health record information is divided into discrete fields, and may be enumerated, numeric or codified.

Examples of structured health information include:
- patient address (non-codified, but discrete field
- diastolic blood pressure (numeric
- coded result observation
- coded diagnosis
- patient risk assessment questionnaire with multiple-choice answers

Context may determine whether or not data are unstructured, e.g., a progress note might be standardized and structured in some EHR-S (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.

Managing healthcare data includes capture, retrieval, deletion, correction, amendment, and augmentation. Augmentation refers to providing additional information regarding the healthcare data, which is not part of the data itself, e.g. linking patient consents or authorizations to the healthcare data of the patient.
Show Full Text
Well Child/Preventive CareHeaderno
Scroll To Top