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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-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-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-2006Ability to access family history, including all guardians and caregivers2015 Priority ListThe system shall provide the ability to record information about all guardians and caregivers (biological parents, foster parents, adoptive parents, guardians, surrogates, and custodians siblings, and case workers; with contact information for each.Child Abuse Reporting, Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementyes
Req-517Ability to access family history, including all parents2013 FormatThe system SHALL provide the ability to access family history, including all parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers; with contact information for each.Child Abuse ReportingNormative Statementsno
Req-520Ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings2013 FormatThe system SHALL provide the ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings (both sexual and physical documentation of laboratory studies, and radiographic studies.Child Abuse ReportingNormative Statementsno
Req-519Ability to access, store, and retrieve the date, time, and place of the occurrence2013 FormatThe system SHALL provide the ability to access, store, and retrieve the date, time, and place of the occurrence of alleged abuse.Child Abuse ReportingNormative Statementsno
Req-525Ability to allow parents/legal guardians and children add any relevant additional health information2013 FormatThe system SHOULD allow parents/legal guardians and children of appropriate age to add any relevant additional health information and fill in gaps in their EHR.Patient Portals - PHRNormative Statementsno
Req-545Ability to comply with industry standards for interfaces and services2013 FormatThe system SHALL comply with industry standards for interfaces and services within the limitations of currently accepted standardsRegistry LinkagesNormative Statementsno
Req-544Ability to comply with registry sharing/linking regulations and standards2013 FormatThe system SHALL comply with registry sharing/linking regulations and standards (HIPAA, HITECH, CHIPRA, etc.Registry LinkagesNormative Statementsno
Req-831Ability to customize age unit thresholds2013 FormatThe system SHOULD enable implementation-specific customization of the age unit thresholds.Well Child/Preventive CareNormative Statementsno
Req-558Ability to document limitations on the patient's parents' level of authority2013 FormatThe system SHALL provide the ability to document limitations on the patient's parents' level of authority to make decisions on behalf of the patient or access health information about the patient.Security and ConfidentialityNormative Statementsno
Req-559Ability to document parental (guardian) notification or permission2013 FormatThe system SHALL provide the ability to document parental (guardian notification or permission for consenting minors to receive some treatments as required by institutional policy or jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-2008Ability to document parental (guardian) notification or permission2015 Priority ListThe system shall provide the ability to document parental (guardian notification or permission for consenting minors to receive some treatments as required by institutional policy or jurisdictional law.Security and Confidentiality, Parents and Guardians and Family Relationship DataNormative Statementyes
Req-845Ability to exclude data points from growth charts2013 FormatFor all growth charts the system SHOULD allow for the exclusion of selected data points, as in when a patient presents with an acute abnormality that affects the measurement (e.g., acute dehydrationGrowth Data, Primary Care ManagementNormative Statementsno
Req-723Ability to incorporate risk factors and/or anticipatory guidance2013 FormatThe system MAY incorporate risk factors and/or anticipatory guidance relevant to body composition, age, and gender into display/printout of growth charts.Growth DataNormative 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-862Ability to record tare weight for DME2013 FormatThe system SHALL allow recording of tare weight for durable medical equipment such as wheelchairs and walkers to facilitate easy weighing of children with special needs.Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-518Ability to retrieve, capture, store, and display information regarding forensic evaluations2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display information regarding forensic evaluations.Child Abuse ReportingNormative 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-522Ability to retrieve, capture, store, and display service plans, progress summaries, and assessments2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display service plans, progress summaries, and assessments.Child Abuse ReportingNormative Statementsno
Req-1065Ability to route and track patient disease management plans, etc. to recipients in local registry2013 FormatThe system MAY provide the ability to version, route and track patient disease management plans, school medication administration forms, early intervention and WIC referrals, etc. to recipients in local service provider registry by preferred routing method (e.g. fax or electronicChildren with Special Healthcare NeedsNormative Statementsno
Req-732Ability to search service registries2013 FormatService registry entries SHOULD be searchable by name, location, service categories provided, and/or parent organization.Children with Special Healthcare NeedsNormative Statementsno
Req-1064Ability to send non-medication orders, referrals, and updates to receiving systems2013 Format
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company,...
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company, home care provider, case management, and mental, dental, and visual health services, when standard interfaces are available.
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Children with Special Healthcare NeedsNormative Statementsno
Req-1286Abnormal screen follow-up2013 FormatThe system SHOULD provide prompts to follow-up after an abnormal screening result.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1053Access & Interoperability2013 FormatAccess and interoperability refers to the ability of school-based systems to provide access to and/or bi-directional sharing of data with external systems in standard formats.School-Based LinkagesFunctionno
Req-587Access custom clinical summaries2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1183Access restraining and visitation order information from external source2013 FormatThe system MAY provide the ability to access, store, and retrieve from an external information source (e.g. registry any restraining or visitation orders, and the person or organization with decision making authority.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-639Access to age-specific guidelines2013 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.
EPSDT, Well Child/Preventive CareNormative Statementsyes
Req-1055Access to child's medical records2013 FormatThe system SHALL enable appropriate access to the child's medical record to school-based clinicians.School-Based LinkagesNormative Statementsno
Req-471Access to patient data-specific materials2013 FormatThe system SHOULD provide access to display and print relevant provider/layperson treatment procedure standards/training; medical/psychological/behavioral condition education materials; and related management guidelines based on coded patient data in the system (e.g. InfobuttonChildren with Special Healthcare Needs, Patient Portals - PHRNormative Statementsno
Req-1141Access to registries2013 FormatThe system SHOULD provide the ability to add, change, or remove access to registriesImmunizations, Registry LinkagesNormative Statementsno
Req-1056Access to school-based health record2013 FormatThe system SHOULD enable appropriate access to the school-based health record for requesting providers and SHALL capture, where necessary, parent/guardian authorization to share data in the record, with adequate specificity as to what information is allowed to be shared, with which caregivers (both clinical and non-clinical and for what purpose.School-Based LinkagesNormative Statementsno
Req-614Acknowledge receipt of new results2013 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.
Primary Care ManagementNormative Statementsno
Req-931Additional medications during pregnancy2013 FormatThe system SHALL record any additional prescription and non-prescription medications and supplements (with name, dose, frequency, and route that the mother took during pregnancy.Birth InformationNormative Statementsno
Req-965Additional quality measures2013 Format
The system SHOULD be able to capture, retrieve, export, and display codified data for user-defined or other endorsed quality measures, such as National Quality Forum (NQF Physician Quality Reporting System (PQRS, formerly known as the...
The system SHOULD be able to capture, retrieve, export, and display codified data for user-defined or other endorsed quality measures, such as National Quality Forum (NQF Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Initiative National Association of Children's Hospitals and Related Institutions (NACHRI National Initiative for Children's Healthcare Quality (NICHQ or state-endorsed. This includes "numerator" elements (e.g., the number of times that a particular service was delivered and "denominator" elements (e.g., the size of the population that should receive the service of interest within a user-specified time frame.
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Quality MeasuresNormative Statementsno
Req-959Adjust head circumference display for prematurity2013 FormatThe system SHALL be able to display head circumference adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsyes
Req-960Adjust length display for prematurity2013 FormatThe system SHOULD be able to display length adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
Req-961Adjust weight display for prematurity2013 FormatThe system SHOULD be able to display weight adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
Req-252Administrative Transaction Processing2013 Format
STATEMENT: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
DESCRIPTION: Support the creation...
STATEMENT: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
DESCRIPTION: Support the creation (including using external data sources, if necessary electronic interchange, and processing of transactions listed below that may be necessary for encounter management during an episode of care.
· The EHR system shall capture the patient health-related information needed for administrative and financial purposes including reimbursement.
· Captures the episode and encounter information to pass to administrative or financial processes (e.g. triggers transmissions of charge transactions as by-product of on-line interaction including order entry, order statusing, result entry, documentation entry, medication administration charting
· Automatically retrieves information needed to verify coverage and medical necessity.
· As a byproduct of care delivery and documentation: captures and presents all patient information needed to support coding. Ideally performs coding based on documentation.
· Clinically automated revenue cycle - examples of reduced denials and error rates in claims.
· Clinical information needed for billing is available on the date of service.
· Physician and clinical teams do not perform additional data entry / tasks exclusively to support administrative or financial processes.
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Registry LinkagesFunctionno
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-1253Adolescent permission for parental information access2013 FormatThe system SHOULD support the documentation of adolescent patient permission to release information to parents and/or guardians.Security and ConfidentialityNormative Statementsno
Req-1217Adoption history2013 Format
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information...
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information captured might not be clinically relevant. Further, the decision support relying on family history may be irrelevant and therefore the EHR system should exclude family history of adoptee in decision support logic.
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Child WelfareNormative Statementsno
Req-2031Adoption history2015 Priority ListThe system shall have the ability to record a child's adoption history.Child WelfareNormative Statementyes
Req-824Age Precision2013 FormatBecause children change substantially during the first several years of life, their age must be calculated more precisely (during that period than that of adults, often with units considerably smaller than years.Well Child/Preventive CareFunctionno
Req-827Age Presentation2013 FormatAge PresentationWell Child/Preventive CareHeaderno
Req-828Age Unit Selection2013 FormatAge units must be appropriate to the actual age, required precision, social conventions, and the environment of care.Well Child/Preventive CareFunctionno
Req-1250Age of emancipation2013 FormatThe system SHOULD record the patient's age of emancipation.Security and ConfidentialityNormative Statementsno
Req-2040Age of emancipation2015 Priority ListThe system shall provide the ability to record the patient's emancipated minor status.Security and ConfidentialityNormative Statementyes
Req-1079Age specific preventive care referrals2013 FormatThe system SHALL provide access to age specific preventive care referrals relevant to proposed preventive care.Well Child/Preventive CareNormative Statementsno
Req-830Age unit threshold implementation rules2013 FormatThe system SHOULD develop age unit threshold implementation rules that account for the variable lengths of months.Well Child/Preventive CareNormative Statementsno
Req-1090Age- and gender-specific decision support2013 FormatData for decision support SHALL be interpreted in an age- and gender-specific fashion, using age- and gender-specific norms, and using age-appropriate data.Well Child/Preventive CareNormative Statementsno
Req-1241Age- and weight-specific single dose range checking2013 FormatThe system SHALL provide the ability to detect a drug dose that falls outside the min-max range based on the patient's age, weight, and maximum recommended adult dose, for a single dose for the medication.Medication ManagementNormative Statementsyes
Req-2037Age- and weight-specific single dose range checking2015 Priority ListThe system shall provide medication dosing decision support that detects a drug dose that falls outside the minimum-maximum range based on the patient's age, weight, and maximum recommended adult dose (if known or maximum recommended pediatric dose (if known for a single dose of the medication.Medication ManagementNormative Statementyes
Req-1078Age- specific educational materials2013 FormatThe system SHALL provide access to age specific patient and parent/caregiver educational materials relevant to proposed preventive care.Well Child/Preventive CareNormative Statementsno
Req-1086Age-appropriate notifications2013 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.
EPSDT, Patient Portals - PHR, Well Child/Preventive CareNormative Statementsno
Req-1172Age-based educational cues2013 FormatThe system SHOULD provide age-based educational cues for healthcare providers and patients. For example, the system MAY implement age-based educational materials provided by the American Academy of Pediatrics' Bright Futures toolkit.Primary Care ManagementNormative Statementsno
Req-2029Age-based educational cues2015 Priority ListThe system shall provide pediatric age-specific clinical decision support covering Bright Futures-based health supervision and anticipatory guidance.Primary Care ManagementNormative Statementyes
Req-988Age-specific ROS2013 FormatIf Review of Systems (ROS is composed of structured data then it SHALL allow age-specific content.Well Child/Preventive CareNormative Statementsno
Req-1239Age-specific daily dose range checking2013 FormatThe system SHALL provide the ability to detect a daily dose that exceeds the recommended range for patient age or maximum recommended adult dose whichever is smaller.Medication ManagementNormative Statementsno
Req-2025Age-specific decision support2015 Priority ListThe system shall report on age-specific Bright Futures-based screening and preventive care opportunities for an individual patient in the practice.Well Child/Preventive CareNormative Statementyes
Req-972Age-specific preventive encounters2013 FormatThe system SHALL support age-specific preventive well-child encounters with content based on age-appropriate recommendations such as Medicaid EPSDT (Early and Periodic Screening, Diagnostic & Treatment and Bright Futures periodicity schedules.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1168Age-specific protocols2013 FormatThe system SHOULD provide for the management and inclusion of protocols that can be differentiated and implemented based on patient age. For example, fever work-up for patients less than 28 days old, vs. fever work-up for patients greater than 28 days old but less than 90 days old.Primary Care ManagementNormative Statementsno
Req-1073Age-specific screening forms2013 FormatThe system SHOULD support age-specific screening forms, including forms with content based on age-appropriate recommendations such as state-designated EPSDT (Early and Periodic Screening, Diagnostic & Treatment tools and Bright Futures Guidelines.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1070Age/gender-specific pre-visit history/screening/prevention forms2013 FormatThe system SHALL support patient/parent completion of pre-visit history forms selected by specific age and gender relevant screening/preventive care questions (e.g. ASQ or PEDSWell Child/Preventive CareNormative Statementsyes
Req-918Alcohol use during pregnancy2013 FormatThe system SHALL record alcohol use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of alcohol used per day.Birth InformationNormative Statementsno
Req-659Alert based on age-specific norms2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsyes
Req-2013Alert based on age-specific norms2015 Priority List
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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.
Well Child/Preventive Care, Primary Care ManagementNormative Statementyes
Req-1231Alert for foster care without Medicaid2013 FormatThe system SHALL have the ability to provide an option to alert where a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementsno
Req-2034Alert for foster care without Medicaid2015 Priority ListThe system shall have the ability to provide an option to alert when a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementyes
Req-1107Alert for identical vaccine dose order2013 FormatIF a vaccine dose/identifier is linked to a specific patient record AND a provider orders/prescribes that dose for a different patient, THEN the system SHALL notify the prescriber for order cancellation or override/documentation.ImmunizationsNormative Statementsno
Req-884Alert for invalid dose computation data2013 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.
Medication ManagementNormative Statementsno
Req-1135Alert for ordered immunizations not forecasted2013 FormatIF a vaccine dose order is not indicated in the immunization forecast for a patient, THEN the system SHALL provide an alert to the provider ordering the dose and to the nurse administering the dose.ImmunizationsNormative Statementsno
Req-885Alert for unavailable pediatric dosing2013 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.
Medication ManagementNormative Statementsno
Req-868Alert to obtain height when BMI required2013 FormatThe system MAY allow alerting to indicate the need to obtain a height when a BMI is required (by policy or guidelineGrowth DataNormative Statementsno
Req-594Allergy occurrence date2013 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.
Well Child/Preventive CareNormative Statementsno
Req-2009Allow unknown patient sex2015 Priority List
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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.
Genetic information, Birth Information, Prenatal ScreeningNormative Statementyes
Req-891Alternative administration techniques2013 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.
Medication ManagementNormative Statementsno
Req-648Alternative dosing weight2013 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.
Medication ManagementNormative Statementsyes
Req-584Amend administrative or financial data2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-923Amphetamine use during pregnancy2013 FormatThe system SHALL record amphetamine use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of amphetamine used per day.Birth InformationNormative Statementsno
Req-1121Annotate immunization record2013 FormatThe system SHOULD provide the ability to annotate a patient immunization record.ImmunizationsNormative Statementsno
Req-872Anthropometric prescribing support2013 FormatMost pediatric drug dosing is weight-based. Sometimes drug dosing is based on body surface area or other anthropometric measures (e.g., oncology drugsGrowth DataHeaderno
Req-1069Anticipatory guidance based on preventive Service Guidelines2013 FormatThe system SHALL display or print age/gender-specific anticipatory guidance based on preventive service guidelines (such as Bright Futures (e.g. sleep, development, injury prevention, behavior, and nutrition and document the completion of specific services.Well Child/Preventive CareNormative Statementsno
Req-553Assign parts of the EHR to another patient identifier2013 FormatThe system SHOULD provide the ability to assign parts of the electronic health record to another patient identifier and delete them permanently from the former according to organizational policy or jurisdictional law relating to protections of birth records of adoptees.Patient Identifier, Security and ConfidentialityNormative Statementsno
Req-2021Associate mother's demographics with newborn2015 Priority ListThe system shall provide the ability to associate multiple identifying parent or guardian demographic information, such as relationship to child, street address, telephone number, and/or email address for each individual child.Patient Identifier, Parents and Guardians and Family Relationship DataNormative Statementyes
Req-992Associate mother’s demographics with newborn2013 FormatThe system SHALL provide the ability to associate elements of the mother's demographic information, aside from name and other personal identifiers, with each baby in the single or multiple birth situation.
Example: Street address, telephone number, email address but NOT mother's date of birth, driver's license, etc.
Patient IdentifierNormative Statementsno
Req-1032Asthma Severity Scoring2013 FormatThe system SHALL support Asthma Severity Scoring.Specialized Scales/ScoringNormative Statementsno
Req-666Audit trails2013 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 DataNormative Statementsno
Req-275Auditable Records2013 Format
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time...
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time stamping implies the ability to indicate the time zone where it was recorded (time zones are described in ISO 8601 Standard Time Reference Auditable records extend to information exchange, to audit of consent status management (to support Req-256 (HL7 ID: DC.1.3.3 and to entity authentication attempts. Audit functionality includes the ability to generate audit reports and to interactively view change history for individual health records or for an EHR-S.
DESCRIPTION: Audit functionality extends to security audits, data audits, audits of data exchange, and the ability to generate audit reports. Audit capability settings should be configurable to meet the needs of local policies. Examples of audited areas include:
- Security audit, which logs access attempts and resource usage including user login, file access, other various activities, and whether any actual or attempted security violations occurred
- Data audit, which records who, when, and by which system an EHR record was created, updated, translated, viewed, extracted, or (if local policy permits deleted. Audit-data may refer to system setup data or to clinical and patient management data
- Information exchange audit, which records data exchanges between EHR-S applications (for example, sending application; the nature, history, and content of the information exchanged and information about data transformations (for example, vocabulary translations, reception event details, etc.
- Audit reports should be flexible and address various users' needs. For example, a legal authority may want to know how many patients a given healthcare provider treated while the provider's license was suspended. Similarly, in some cases a report detailing all those who modified or viewed a certain patient record
- Security audit trails and data audit trails are used to verify enforcement of business, data integrity, security, and access-control rules
-There is a requirement for system audit trails for the following events:
>Loading new versions of, or changes to, the clinical system;
>Loading new versions of codes and knowledge bases;
>Taking and restoring of backup;
>Changing the date and time where the clinical system allows this to be done;
>Archiving any data;
>Re-activating of an archived patient record;
>Entry to and exiting from the clinical system;
>Remote access connections including those for system support and maintenance activities
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Growth DataFunctionno
Req-1206Authenticated external access to chart2013 FormatThe system MAY facilitate the ability to search and retrieve certain patient records for an appropriately authenticated external party that requires access to a child's health information.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1218Authorized non-clinician viewers of EHR data2013 FormatThe system SHOULD have the ability to display clinical information to authorized non-clinician viewers of EHR data, such as child welfare case workers and other authorized members of the child's care team.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-2032Authorized non-clinician viewers of EHR data2015 Priority ListThe system shall have the ability to identify members of the care team (including professional and nonprofessional members and indicate their roles/relationships to the child.Child Welfare, Patient Portals - PHRNormative Statementyes
Req-1219Authorized user details2013 FormatThe system SHALL have the ability to capture and display the name, contact information, and relationship/role of each authorized viewer of EHR data.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-1197Auto-populate birth certificate2013 FormatThe system SHOULD be able to auto-populate a birth certificate.Birth InformationNormative Statementsno
Req-668Automate data retrieval2013 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.
Registry LinkagesNormative Statementsno
Req-1268Automatically generate age-appropriate developmental questionnaires2013 FormatThe system SHALL have rule-based business intelligence that allows it to automatically generate age-appropriate questionnaires of the correct type which are then presented to the correct person.Well Child/Preventive CareNormative Statementsno
Req-619BMI and growth velocity2013 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 DataNormative Statementsno
Req-1043Bayley Scales of Infant Development2013 FormatThe system SHALL support the Bayley Scales of Infant Development.Specialized Scales/ScoringNormative Statementsno
Req-927Betamethasone prior to delivery2013 FormatThe system SHOULD record the date and time of all Betamethasone doses given to the mother prior to delivery.Birth InformationNormative Statementsno
Req-989Birth Demographics2013 FormatIn either single or multiple births the mother's demographics, except for name, are associated with the child. Additionally, the names initially given the baby(ies may be simply "Baby 1," "Baby 2," etc.Patient IdentifierHeaderno
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-93Birth date format2013 FormatThe system SHALL record Birth Date (MM:DD:YYYYBirth InformationNormative Statementsno
Req-1198Birth information to state vital statistics registry2013 FormatThe system SHOULD provide birth information to the appropriate state vital statistics registry.Birth Information, Registry LinkagesNormative Statementsno
Req-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative Statementsno
Req-897Birth weight in kg2013 FormatThe system SHALL record birth weight in kilograms to 3 decimal places.Birth InformationNormative Statementsno
Req-977Blood pressure norms2013 FormatThe system SHALL provide age-, gender-, and height-specific norms and percentiles for blood pressure measurements.Well Child/Preventive CareNormative Statementsyes
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
Req-1289Blood-lead testing2013 FormatThe system SHOULD alert when blood-lead testing is needed.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-863Body Mass Index2013 FormatBody mass index (BMI is a calculated, based on weight and height. Currently, normative data exist only for children 2 and older. It is usually measured at all well-child visits, but can be assessed at other times based on clinician concern.Children with Special Healthcare Needs, Growth Data, Well Child/Preventive CareFunctionno
Req-626Bone age2013 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 DataNormative 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-634Breast milk aliquot data2013 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.
Well Child/Preventive CareNormative 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-964CHIPRA-required quality measures2013 Format
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood...
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood immunization status in a clinic over 1 year beginning in January 2011, or weight assessment for children/adolescents over 2 months beginning in March 2011.
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Quality MeasuresNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
Req-864Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal place at every well-child visit beginning at 24 months of life.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-865Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal point at any age based on system query.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-117Calculate growth velocity2013 FormatThe system SHOULD calculate growth velocity between two points on the growth chart selected by the user.Growth DataNormative Statementsno
Req-825Calculate patient age precisely enough to support environment-specific activities2013 FormatThe system SHALL calculate patient age precisely enough to support environment-specific activities that vary significantly in the first hours, days, and months of life.Well Child/Preventive CareNormative Statementsno
Req-826Calculate patient age to the minute2013 FormatThe system SHOULD calculate patient age no less precisely than the nearest minute for at least the first week of lifeWell Child/Preventive CareNormative Statementsno
Req-125Capture Data and Documentation from External Clinical Sources2013 FormatIncorporate clinical data and documentation from external sources. Mechanisms for incorporating external clinical data and documentation (including identification of source such as image documents and other clinically relevant data are available. Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate.Birth InformationFunctionno
Req-248Capture Patient Health Data Derived from Administrative and Financial Data and Documentation2013 Format
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data...
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data derived from administrative or financial data from clinically authenticated data. Sources of administrative and financial data relating to a patient's health may provide this data for entry into the health record or be given a mechanism for entering this data directly. The data must be explicitly labeled as derived from administrative or financial data, and information about the source must be linked with that data. Patient health data that is derived from administrative or financial data may be provided by:
1. the patient
2. a provider
3. a payer, or
4. entities that transmit or process administrative or financial data.
Since this data is non-clinical, it may not be authenticated for inclusion in the patient's legal health record. Registration data, which may contain demographic data and pertinent positive and negative histories, is an example of administrative and financial data that may be captured.
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Parents and Guardians and Family Relationship DataFunctionno
Req-560Capture Patient-Originated Data2013 Format
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish...
STATEMENT: Capture and explicitly label patient originated data, link the data source with the data, and support provider authentication for inclusion in patient health record.
DESCRIPTION: It is critically important to be able to distinguish patient-originated data that is either provided or entered by a patient from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-originated data intended for use by providers will be available for their use.
Data about the patient may be appropriately provided by:
1. the patient
2. a surrogate (parent, spouse, guardian or
3. an informant (teacher, lawyer, case worker
An electronic health record may provide the ability for direct data entry by any of these.
Patient-originated data may also be captured by devices and transmitted for inclusion into the electronic health record.
Data entered by any of these must be stored with source information. A provider must authenticate patient-originated data included in the patient's legal health record.
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Patient Portals - PHRFunctionno
Req-481Capture and communicate referrals2013 FormatThe system SHALL provide the ability to capture and communicate referral(s to other care provider (s or agencies, whether internal or external to the organization.Primary Care ManagementNormative Statementsno
Req-1108Capture and document overrides of immunization notifications2013 Format
IF a provider overrides an immunization notification THEN the system MAY prompt the prescriber for documentation and attestation supporting the override, comprised of: a vaccine dose identifiers, b the patient for whom the dose was...
IF a provider overrides an immunization notification THEN the system MAY prompt the prescriber for documentation and attestation supporting the override, comprised of: a vaccine dose identifiers, b the patient for whom the dose was originally intended, c the patient who received the dose, d the current prescriber (if different from the original provider ordering the dose e the reason for the override and f signature.
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ImmunizationsNormative Statementsno
Req-901Capture and record Birth Order for Multiple Births2013 FormatIf an infant is not a singleton, the system SHALL record the birth order.Birth Information, Patient IdentifierNormative Statementsno
Req-506Capture both presence and absence of conditions in history2013 FormatThe system SHALL provide the ability to capture patient history as both a presence and absence of conditions, i.e., the specification of the absence of a personal or family history of a specific diagnosis, procedure or health risk behavior.Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementsno
Req-1186Capture child abuse details2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history...
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history specific sexual acts; and mechanism of injury in separate sections (e.g. one section for alleged perpetrator and one section for child
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Child Abuse ReportingNormative Statementsno
Req-640Capture continuum of care processes2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1162Capture data that precedes the newborn’s record2013 FormatThe system SHALL allow capture of data that were collected for a newborn before the newborn's electronic record was created.Prenatal ScreeningNormative Statementsyes
Req-1157Capture maternal problem list2013 FormatThe system SHALL enable selective capture into the child's chart of the maternal problem list by the child's healthcare provider.Prenatal ScreeningNormative Statementsno
Req-597Capture medication dates2013 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.
Medication ManagementNormative Statementsno
Req-1235Capture medication dosing details2013 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.
Medication ManagementNormative Statementsno
Req-1074Capture patient relationships2013 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.
Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsyes
Req-110Capture patient vital signs2013 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 DataNormative Statementsyes
Req-1113Capture vaccine administration data from multiple input tools2013 FormatThe system SHOULD provide the ability to capture vaccine administration data from multiple input tools such as keyboard, bar-coding and radio-frequency identification devices.ImmunizationsNormative 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-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-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-1080Care plan items in assigned tasks2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1081Care planned items in tracked tasks2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1066Caregiver contact information for children with special healthcare needs2013 FormatThe system SHALL provide the ability to capture the names and contact information for primary provider, case managers, and subspecialists that follow a child with special healthcare needs, including their contact information.Children with Special Healthcare Needs, Well Child/Preventive CareNormative Statementsno
Req-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
Req-1042Child Autism Rating Scale (CARS)2013 FormatThe system SHALL support the Child Autism Rating Scale (CARSSpecialized Scales/ScoringNormative Statementsno
Req-892Child-appropriate doses in provider-specific medication lists2013 FormatThe system SHALL support child-appropriate dosing in provider specific medication lists ("favorites" including default route, dose, frequency, and quantity (e.g. accommodate weight-based doses such as <mg or mcg or gm>/kg/dose or <mg or mcg or gm>/kg/dayMedication ManagementNormative Statementsno
Req-1237Child-specific therapeutic substances2013 FormatThe system SHOULD enable the ordering of child-specific therapeutic substances, and support units appropriate to children.Medication ManagementNormative Statementsno
Req-115Childhood obesity statistics2013 FormatSystem MAY store and display waist circumference and hip circumference and calculate/display waist to hip ratio in patients identified with obesity or cardiovascular risk.Growth DataNormative Statementsno
Req-642Choice of action based on care plan2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1170Chronic disease and age-specific educational materials2013 FormatThe system SHOULD incorporate chronic disease and age-specific educational materials, for example diabetes and asthma.Primary Care ManagementNormative Statementsno
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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Headerno
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-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-576Clinical Workflow Tasking2013 Format
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment....
STATEMENT: Schedule and manage tasks with appropriate timeliness.
DESCRIPTION: Since the electronic health record will replace the paper chart, tasks that were based on the paper artifact must be effectively managed in the electronic environment. Functions must exist in the EHR-S that support electronically any workflow that previously depended on the existence of a physical artifact (such as the paper chart, a phone message slip in a paper based system. Tasks differ from other more generic communication among participants in the care process because they are a call to action and target completion of a specific workflow in the context of a patient's health record (including a specific component of the record Tasks also require disposition (final resolution The initiator may optionally require a response. For example, in a paper based system, physically placing charts in piles for review creates a physical queue of tasks related to those charts. This queue of tasks (for example, a set of patient phone calls to be returned must be supported electronically so that the list (of patients to be called is visible to the appropriate user or role for disposition. Tasks are time-limited (or finite The state transition (e.g. created, performed and resolved may be managed by the user explicitly or automatically based on rules. For example, if a user has a task to signoff on a test result, that task should automatically be marked complete by the EHR when the test result linked to the task is signed in the system. Patients will become more involved in the care process by receiving tasks related to their care. Examples of patient related tasks include acknowledgement of receipt of a test result forwarded from the provider, or a request to schedule an appointment for a pap smear (based on age and frequency criteria generated automatically by the EHR-S on behalf of the provider.
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Well Child/Preventive CareHeaderno
Req-644Clinical data for research study participants2013 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.
Primary Care ManagementNormative Statementsno
Req-1060Clinical decision support for code status2013 FormatThe system SHOULD support the ability to prompt for the provider (appropriate to local processes and workflow to discuss code status with the parent/guardian of a medically complex child with special health care needs upon an initial health & physical evaluation.Children with Special Healthcare NeedsNormative Statementsno
Req-1166Clinical decision support tools2013 FormatThe system SHOULD incorporate clinical decision support tools and utilities that support severity assessment and mortality prediction, a minimum data set, standardized terminology, and validated indicators for such common chronic diseases as asthma.Primary Care ManagementNormative Statementsno
Req-1220Clinical issues displayed to non-clinicians2013 FormatThe system SHOULD have the ability to display known interaction effects, known concerns and side-effects, or contraindications to authorized viewers of data external to clinicians, such as child welfare case workers.Child WelfareNormative Statementsno
Req-945Clinical staff at delivery2013 FormatThe system SHALL record the pediatrician(s nurse(s and respiratory therapist(s present at delivery.Birth InformationNormative Statementsno
Req-451Closest available standardized dose2013 FormatThe system MAY inform the ordering provider about the closest available standardized dose after calculating the dose based on patient age and weight.Medication ManagementNormative Statementsno
Req-2005Closest available standardized dose2015 Priority ListThe system shall inform the ordering provider about the closest available standardized dose after calculating the dose based on patient age and weight and other factors.Medication ManagementNormative Statementyes
Req-921Cocaine use during pregnancy2013 FormatThe system SHALL record cocaine use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of cocaine used per day.Birth InformationNormative Statementsno
Req-1059Code status for children with special healthcare needs2013 FormatThe system MAY selectively include code status on the Health & Physical Evaluation template for a child designated as medically complex and/or with special health care needs.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsno
Req-458Coded disease measure goals and thresholds2013 FormatThe system SHOULD capture/calculate coded individualized disease measure goals and thresholds for modifying care (e.g. peak flow, FEV1, HgA1c, or behavioral goals used in self-care and inpatient treatment plansChildren with Special Healthcare Needs, Primary Care Management, Quality MeasuresNormative Statementsno
Req-649Combination drug dosage functions2013 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.
Medication ManagementNormative Statementsno
Req-1264Combine imported and directly entered childhood development data2013 FormatThe system SHALL combine information gathered from outside sources with information directly entered into the EHR in order to derive contextually complete reports of childhood development.
Well Child/Preventive CareNormative Statementsno
Req-472Communicate with local service registries2013 FormatThe system SHOULD provide the ability to search, view, and contribute to local service registries that include providers, medical home practices or services, durable medical equipment (DME skilled nursing facilities (SNF social service programs, etc. and detail services, insurance affiliation, and preferred contact method for notes, referrals, and orders.Children with Special Healthcare NeedsNormative Statementsno
Req-1174Communication during care and follow-up care2013 FormatThe system SHALL incorporate support communication during care and follow-up care and communication of data between different disciplines.

Example: A system can support communication with school nurses, day care providers and other professional caregivers.
Primary Care ManagementNormative Statementsyes
Req-1277Communication with non-medical professionals2013 FormatThe system SHOULD have the ability to communicate with non-medical professionals electronically requesting information or referral services.
Well Child/Preventive CareNormative Statementsno
Req-1052Compare Growth Charts2013 FormatThe system MAY allow for the display of multiple growth charts (such as for weight, length or height and head circumference in a single screen or view.Growth DataNormative Statementsno
Req-636Compare patient assessments to best practices2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1263Compare questionnaire results to national normative values2013 FormatThe system SHALL have the ability to compare imported questionnaire results data to national normative values.Well Child/Preventive CareNormative Statementsno
Req-1276Compendia of state and local laws2013 FormatThe system SHOULD have a compendium of state and local laws and regulations related to non-medical psychosocial problems that are available to the staff for reference.

Well Child/Preventive CareNormative Statementsno
Req-1242Compounded drug dosage computations2013 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.
Medication ManagementNormative Statementsno
Req-583Compute post conceptional age2013 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.
Birth Information, Growth Data, Prenatal ScreeningNormative Statementsno
Req-646Compute weight-based drug dosage2013 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.
Medication ManagementNormative Statementsno
Req-2012Compute weight-based drug dosage2015 Priority List
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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.
Medication ManagementNormative Statementyes
Req-1044Conners Comprehensive Behavior Rating Scales2013 FormatThe system SHALL support the Conners Comprehensive Behavior Rating Scales (Conners CBRS™Specialized Scales/ScoringNormative Statementsno
Req-1136Context for recommended immunizations not given2013 FormatThe system SHALL provide the ability to capture and output (documentation and display vaccine doses that have been recommended by the system but not ordered or administered (including the date of recommendation and reason for not ordering or administering.ImmunizationsNormative Statementsyes
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-1102Controlled access to registries data2013 FormatThe system MAY enable controlled access to and display of data contained in registries such as immunizations.Immunizations, Patient Portals - PHRNormative Statementsno
Req-1007Copy and paste selected information from another medical record/chart2013 Format
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL...
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL support suppression of the maternal identity in cases that require parental confidentiality (e.g. voluntary surrender for adoption, or removal from the mother's care for other reasons
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Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-878Correct growth data2013 FormatThe system SHALL have a process to correct growth data. This process shall include a method to track changes.Growth DataNormative Statementsno
Req-879Correct growth data directly from growth chart2013 FormatThe system SHOULD allow the user to correct growth data directly from the growth chart, by interacting directly with the graphical data point, rather than having to first go to a tabular (flowsheet representation.Growth DataNormative Statementsno
Req-586Create custom clinical summaries2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-480Create detailed referral orders2013 FormatThe system SHALL provide the ability to create referral orders with detail adequate for correct routing, including referrals to outside agencies or providers.Primary Care ManagementNormative Statementsno
Req-638Create site-specific care plans and guidelines from standard ones2013 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.
Well Child/Preventive CareNormative Statementsno
Req-670Custom patient record reports2013 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.
Well Child/Preventive CareNormative Statementsno
Req-675Customize reports to mandated formats2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1123Customized immunization reports2013 FormatThe system SHOULD provide the ability for users (based on role and authorization to specify reports based on EHR patient data on immunization status.Immunizations, Well Child/Preventive CareNormative Statementsno
Req-1062DME and nursing needs2013 FormatThe system SHALL capture Durable Medical Equipment (DME and nursing needs for the child with identification of age-appropriate resources and orderables.Children with Special Healthcare NeedsNormative Statementsno
Req-2022DME and nursing needs2015 Priority ListThe system shall capture Durable Medical Equipment (DME and nursing needs for the child with identification of age-appropriate resources and orderables.Children with Special Healthcare NeedsNormative Statementyes
Req-104Data and Documentation From External Sources2013 FormatExternal sources are those outside the EHR system, including clinical, administrative, and financial information systems, other EHR systems, PHR systems, and data received through health information exchange networks.Birth Information, Parents and Guardians and Family Relationship Data, Patient Portals - PHRHeaderno
Req-658Data elements for pediatric ordering2013 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-609Data pertinent to immunization administration2013 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.
ImmunizationsNormative Statementsno
Req-1184Data related to outcome measures for welfare agencies2013 FormatThe system SHOULD provide the ability to include data elements that are related to federally required outcome measures as may be requested by child welfare agencies.Child Abuse ReportingNormative Statementsno
Req-685Date of allergy documentation2013 FormatThe system SHALL provide the ability to capture and display the date on which allergy information was entered.Medication Management, Well Child/Preventive CareNormative Statementsno
Req-1224Dates of out-of-home care2013 FormatFor children who have ever been in out-of-home care, the system SHOULD have the ability to store and display information about the dates of the out-of-home care.Child WelfareNormative Statementsno
Req-1128Decision support for options on specific vaccine products2013 FormatIF the system recommends a list of antigens for which a patient is eligible THEN the system SHALL provide the ability to give real-time decision support as to options on specific vaccine products (including combination vaccines according to what vaccine products are available.ImmunizationsNormative Statementsno
Req-549Define context for principal authorization2013 FormatThe system MAY provide the ability to define context for the purpose of principal authorization based on identity, role, work assignment, present condition, location, patient consent, or patient's present conditionSecurity and ConfidentialityNormative Statementsno
Req-671Define formal health record2013 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.
Security and ConfidentialityNormative Statementsno
Req-635Define formal health records2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1202Definition of Terms for Parents and Guardians and Family Relationship Data2013 Format
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person...
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person with durable power of attorney for health care for a patient, the executor or administrator of the patient's estate, or the person responsible for the patient's estate if it is not to be probated.
Guarantor: The guarantor is the person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patients 18 years of age and younger.
Medical Decision Maker: the authority who has the ability to make decisions related to the medical care for a youth. Decision authority may be full or limited, with limited typically allowing consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR. For children in group or residential treatment this is the court or child welfare staff.
Full medical decision making authority: Full authority to make medical decisions (such as consent to treatment and procedures on behalf of the minor. Full medical decision making is typically afforded to parents and in the case of foster children to the state social services agency (via a case worker typically
Limited medical decision making authority: Less than full authority for medical decision making; typically limited decision making (as applies to most foster parent situations allows consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR.
Biological Parent: birthparents or natural parents, the man and woman who conceive a child; also known as genetic parents.
Foster Parent: An adult who takes over care of a minor child who has been placed in the foster care system because the child's own family cannot take care of the child or have had custody taken away by a court or agency. (*Foster parent subcategories and definitions of guardianship may vary from state to state.
Adoptive Parent: A person who completes all the requirements to legally adopt a child who is not his or her biological child.
Surrogate Parent: a woman who agrees to be impregnated by a sperm donor and to carry the child to term, at which time the offspring is surrendered to the care of another.
Custodial Parent: the parent who has physical and/or legal custody of his/her child by court order.
Noncustodial Parent: a parent who does not have physical and/or legal custody of his/her child by court order.
Parental rights: The legal rights and corresponding legal obligations that go along with being the parent of a child.
Legal Guardian: An adult to whom the court has given parental responsibility and authority for a child. Appointment as guardian requires the filing of a petition and approval by the court and can be done without terminating the parental rights of the child's parents. Guardian rights vary by state and sometimes by county. A guardian may or may be the medical consenter. Typically, a guardian may be able to give consent for routine medical care and minor surgical procedures, but not for end-of-life decisions such as DNR (Do Not Resuscitate
Guardian of the Estate: Someone who looks after a child's property.
Guardian of the Person: An adult who has legal authority to make personal decisions for the child, including responsibility for his physical, medical, and educational needs. The medical decision making authority of guardian may be limited.
Full Sibling: is a sibling with whom an individual shares the same biological parents.
Half Sibling (half brother or half sister is a sibling with one shared biological parent.
Agnate Sibling: a half-sibling that shares the same father (but different mothers
Uterine Sibling: a half-sibling that shares the same mother (but different fathers
Case worker: is a person that provides social services and assistance to improve the social and psychological functioning of children and their families and to maximize the family well-being and the academic functioning of children. May assist parents, arrange adoptions, and find foster homes for abandoned or abused children. In schools, they address such problems as teenage pregnancy, misbehavior, and truancy. A job as a Child Welfare Caseworker falls under the broader career category of Child, Family, and School Social Workers. Case workers may work for a governmental or private agency.
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Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1050Denver Developmental Screening Test2013 FormatThe system SHOULD support The Denver Developmental Screening Test.Specialized Scales/ScoringNormative Statementsno
Req-1232Descriptors for patient weight2013 FormatThe system SHALL support the capture and recording of patient weight including optional descriptors such as Unknown or Estimated.Medication Management, Well Child/Preventive CareNormative Statementsno
Req-552Determine need for minor patient consent for outside access to content2013 FormatThe system MAY determine the need for minor patient consent to permit outside access to content based on determination of age of majority within a legal jurisdiction, possibly in combination with record content to be accessed.Security and ConfidentialityNormative Statementsno
Req-1040Developmental Scores / Intelligence Tests2013 FormatDevelopmental scores and scales are critical to assessing developmental milestones.Specialized Scales/ScoringFunctionno
Req-599Discrete immunization data2013 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.
ImmunizationsNormative Statementsyes
Req-866Display BMI data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display body mass index (BMI data on both the sex-specific CDC and WHO growth charts.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-867Display BMI data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-1084Display and print an individualized flow sheet of completed preventive care2013 FormatThe system SHOULD display and print an individualized flow sheet of completed age specific preventive care and recommended care.Well Child/Preventive CareNormative Statementsno
Req-1100Display appropriate EHR information to parents and guardians2013 FormatThe system SHOULD enable parents and caregivers to see appropriate information in the electronic health record, including decisions made and, when possible, the clinical rationale for those decisions.Patient Portals - PHRNormative Statementsno
Req-871Display bone age and growth velocity data together2013 FormatThe system SHOULD allow inclusion of bone age data on the same display as the growth velocity data.Growth DataNormative Statementsno
Req-876Display clinical context for each point on growth chart2013 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 DataNormative Statementsno
Req-641Display continuum of care processes2013 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-843Display date of each data point on growth chart2013 FormatFor all growth charts the curve SHOULD provide a display of the date of each data point shown on the curve.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-839Display growth charts2013 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 DataNormative Statementsyes
Req-870Display growth velocity data on normative growth chart2013 FormatThe system SHALL calculate growth velocity from height data, and plot it on normative curves provided by agencies such as CDC and WHO.Growth DataNormative Statementsno
Req-962Display head circumference data on growth charts2013 FormatThe system SHALL be able to display all recorded head circumference data on the sex-specific growth chart.Growth DataNormative Statementsno
Req-850Display head circumference on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-598Display inactive problems2013 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.
Well Child/Preventive CareNormative Statementsno
Req-853Display length/height data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded length/height data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-854Display length/height data on population-specific growth charts2013 FormatThe system MAY display length/height data on selected population-specific growth charts (e.g., children with Down syndrome or a particular ethnicityGrowth DataNormative Statementsno
Req-875Display predictive growth curves2013 FormatThe system MAY display predictive growth curves or growth targets based on mid-parental height or other techniques.Growth DataNormative Statementsno
Req-967Display quality measures graphically2013 FormatThe system SHALL be able to display the quality measures graphically, with multiple time points as selected by the user within the healthcare setting (e.g., run chartsQuality MeasuresNormative Statementsno
Req-1262Display questionnaire results visually2013 FormatThe system SHALL be able to display questionnaire results in a visual format (graphing/chartsWell Child/Preventive CareNormative Statementsno
Req-859Display weight data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded weight data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-860Display weight data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-1190Disposition of abuse allegations from external source2013 Format
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for...
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
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Child Abuse ReportingNormative Statementsno
Req-1189Disposition of abuse allegations within the EHR2013 Format
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions...
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
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Child Abuse ReportingNormative Statementsno
Req-1125Disseminate immunization news to prescribers2013 FormatThe system SHOULD provide the ability to capture and disseminate just-in-time news about vaccine shortages and recalls to prescribers at the point of ordering/prescribing. The news can come from regulatory agencies, supply chain stakeholders and institutional/practice administrators.ImmunizationsNormative Statementsno
Req-1213Distinguish guardian from guarantor2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1153Distinguish maternal from child data2013 FormatWithin the child's record the system SHALL clearly distinguish maternal history data from directly collected child data.Prenatal ScreeningNormative Statementsno
Req-1096Distinguish patient sourced data2013 FormatThe system SHALL clearly distinguish patient sourced/entered data from data received from a clinical system.Patient Portals - PHRNormative Statementsno
Req-1171Document acute primary care education2013 FormatThe system SHOULD provide the ability to document that acute primary care education was provided to parents, guardian, patient, or other caregivers.Primary Care ManagementNormative Statementsno
Req-819Document appropriate newborn screening2013 FormatThe system SHALL document completion of the steps described in http://pediatrics.aappublications.org/content/121/1/192.abstract. Exit DisclaimerNewborn ScreeningNormative Statementsno
Req-590Document assent for patients unable to consent2013 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.
Security and ConfidentialityNormative Statementsno
Req-556Document authority for consent on behalf of minors2013 FormatThe system SHALL allow for documentation of authority of foster parents or custodians to give consent on behalf of a minor patient, including unlimited number of different foster parents or custodians.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-484Document communication with providers or agencies2013 FormatThe system SHALL provide the ability to document in the patient record verbal/telephone communication with providers or agencies whether internal or external to the organization.Child Welfare, Primary Care ManagementNormative Statementsno
Req-1212Document decision-making authority of patient representative2013 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.
Security and ConfidentialityNormative Statementsno
Req-2030Document decision-making authority of patient representative2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Security and ConfidentialityNormative Statementyes
Req-1133Document reason for non-vaccination2013 FormatThe system SHALL provide the ability to document reasons for non-vaccination that MAY include: the prescriber, the patient, and the reason the vaccine dose was not given.ImmunizationsNormative Statementsno
Req-881Document reasons for drug alert override2013 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-663Document recipient of educational material2013 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-557Document time restrictions on authority for consent on behalf of patient2013 FormatThe system SHALL provide the ability to document any time restrictions on the patient's guardian, foster parent or custodian's level of authority to make decisions on behalf of the patient.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-602Document using standard assessments2013 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.
Children with Special Healthcare NeedsNormative Statementsno
Req-119Documentation for patient educational material2013 FormatThe system SHALL provide the ability to document that the educational material was reviewed with the patient and/or patient representative and their comprehension of the material.Growth DataNormative Statementsno
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-893Documentation of compliance and refusal of care2013 FormatThe system MAY provide the ability to require documentation of information regarding patient compliance with prescribed treatment, including parent/guardian refusal of treatment.Medication ManagementNormative Statementsno
Req-1051Draw-a-Person test2013 FormatThe system SHOULD support The Draw-a-Person test (DAP-Goodenough-Harris Drawing TestSpecialized Scales/ScoringNormative Statementsno
Req-887Drug contraindications in specific child populations2013 FormatThe system SHOULD provide the ability to detect contraindications in specific child populations (e.g. age groups or those with liver issues for individual medications and any combined pharmacotherapy and inform the user during ordering.Medication ManagementNormative Statementsno
Req-882Drug dosage computation2013 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 Statementsyes
Req-1115EHR communication with medication management system2013 FormatIF vaccines doses are managed by a vaccine/medication management system, THEN the EHR system SHOULD exchange standard messages with the medication management system.Immunizations, Medication ManagementNormative Statementsno
Req-1194EHR-documented abuse by caregivers2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day...
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
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Child Abuse ReportingNormative Statementsno
Req-1290EPSDT reporting2013 FormatThe system SHOULD be able to generate reports of recommended EPSDT (Early and Periodic Screening, Diagnostic & Treatment services to support annual EPSDT reporting requirements.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-877Editing of Data2013 FormatData editing aspects of the system.Growth DataFunctionno
Req-1251Education of adolescents regarding legal protections2013 FormatThe system SHOULD support documentation of adolescent's education regarding legal protections of health data for adolescents.Security and ConfidentialityNormative Statementsno
Req-1152Electronically import maternal data from multiple sources2013 FormatWhen the maternal prenatal and perinatal record is split across more than one system (e.g. prenatal care and Labor & Delivery and if electronic access is possible, the system SHOULD enable incorporation of maternal information from each of those systems into the child's record.Prenatal ScreeningNormative Statementsno
Req-1150Electronically import maternal data into patient history2013 FormatWhen electronic access to the mother's data is possible, the system SHALL enable incorporation of selected maternal prenatal and perinatal data into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1247Emergency consent documentation2013 FormatThe system SHALL record/document the appropriate data associated with emergency consent, i.e., consent when consent from parents or legal guardians cannot be obtained.Security and ConfidentialityNormative Statementsno
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
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-718Entity Access Control2013 Format
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of...
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of an EHR-S. To ensure that access is controlled, an EHR-S must perform authentication and authorization of users or applications for any operation that requires it and enforce the system and information access rules that have been defined.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
Req-573Entity Authorization.2013 Format
STATEMENT: Manage the sets of access-control permissions granted to entities that use an EHR-S (EHR-S Users
Enable EHR-S security administrators to grant authorizations to users, for roles, and within contexts. A combination of these authorization...
STATEMENT: Manage the sets of access-control permissions granted to entities that use an EHR-S (EHR-S Users
Enable EHR-S security administrators to grant authorizations to users, for roles, and within contexts. A combination of these authorization categories may be applied to control access to EHR-S functions or data within an EHR-S, including at the application or the operating system level.

DESCRIPTION: EHR S Users are authorized to use the components of an EHR-S according to their identity, role, work-assignment, location and/or the patient's present condition and the EHR S User's scope of practice within a legal jurisdiction.
- User based authorization refers to the permissions granted or denied based on the identity of an individual. An example of User based authorization is a patient defined denial of access to all or part of a record to a particular party for privacy related reasons. Another user based authorization is for a tele-monitor device or robotic access to an EHR-S for prescribed directions and other input.
- Role based authorization refers to the responsibility or function performed in a particular operation or process. Example roles include: an application or device (tele-monitor or robotic or a nurse, dietician, administrator, legal guardian, and auditor.
- Context-based Authorization is defined by ISO 10181-3 Technical Framework for Access Control Standard as security-relevant properties of the context in which an access request occurs, explicitly time, location, route of access, and quality of authentication. For example, an EHR-S might only allow supervising providers' context authorization to attest to entries proposed by residents under their supervision.
In addition to the ISO standard, context authorization for an EHR-S is extended to satisfy special circumstances such as, work assignment, patient consents and authorizations, or other healthcare-related factors. A context-based example is a patient-granted authorization to a specific third party for a limited period to view specific EHR records.
Another example is a right granted for a limited period to view those, and only those, EHR records connected to a specific topic of investigation.
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Security and ConfidentialityFunctionno
Req-952Epinephrine in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of epinephrine used during resuscitation.Birth InformationNormative Statementsno
Req-1144Exchange immunization data with PHRs2013 FormatThe system MAY exchange immunization data with personal health records (PHRsImmunizationsNormative Statementsno
Req-1143Exchange immunization information with external sources2013 FormatThe system SHOULD exchange immunization data with external sources (e.g. hospitals, newborn nurseries, emergency departments, and retail-based clinics about vaccines administered to patients. The exchange SHOULD use an established immunization messaging standard.ImmunizationsNormative Statementsno
Req-1255External Sources of Developmental and Behavioral Information2013 Format
Developmental and Behavioral Information requires information from medical as well as non-medical people who interact with a child including but not limited to parents, teachers, and counselors. Developmental Milestones can be divided many ways all...
Developmental and Behavioral Information requires information from medical as well as non-medical people who interact with a child including but not limited to parents, teachers, and counselors. Developmental Milestones can be divided many ways all include some aspect of Physical Development, Social /Personal Skills, Cognitive Development, and Communication Skills. In order for a pediatrician to completely assess a child's developmental progress many external pieces of information must be available to the clinician.
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Well Child/Preventive CareFunctionno
Req-1195Externally documented abuse by caregivers2013 Format
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed...
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
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Child Abuse ReportingNormative Statementsno
Req-1054FERPA compliance2013 FormatThe system SHALL comply with Family Educational Rights and Privacy Act (FERPA rules.School-Based LinkagesNormative Statementsno
Req-1200Family and patient history of intimate partner violence2013 FormatThe system SHOULD have access to history of intimate partner violence of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1199Family and patient history of substance abuse2013 FormatThe system SHOULD have access to history of drug or alcohol abuse of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1201Family and patient history of suicidal ideation or depression2013 FormatThe system SHOULD have access to history of suicidal ideation or depression of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1075Family history linkages2013 FormatThe system SHOULD link family health history data elements to guide clinical care of patient.
Example: Basic genogram functionality is a familiar and efficient method of capturing and displaying these linkages.
Well Child/Preventive CareNormative Statementsno
Req-1192Family history relationships2013 Format
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents...
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.
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Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1209Family member affiliations2013 FormatThe system MAY have access to parents, guardians, siblings and patients' affiliation with religious organizations, community organizations, gangs, etc.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1215Family, psychosocial, and child welfare resources2013 FormatThe system SHOULD have the ability to store, retrieve, and display a list of family, psychosocial, and child welfare resources.Child WelfareNormative Statementsno
Req-950FiO2 administration in neonatal resuscitation2013 FormatThe system SHALL record the FiO2 delivered to the infant during resuscitation.Birth InformationNormative Statementsno
Req-1020Finnegan Neonatal Abstinence Scoring (NAS)2013 FormatThe system SHALL support modified Finnegan Neonatal Abstinence Scoring (NASSpecialized Scales/ScoringNormative Statementsno
Req-730Flag special healthcare needs2013 FormatThe system SHALL support the flagging of individuals with special healthcare needs or complex conditions, to facilitate care management, decision support, and reporting.Children with Special Healthcare NeedsNormative Statementsno
Req-2014Flag special healthcare needs2015 Priority ListThe system shall support the ability for providers to flag or unflag individuals with special health care needs or complex conditions who may benefit from care management, decision support, and care planning; and shall support reporting.Children with Special Healthcare NeedsNormative Statementyes
Req-672Flexible record element order in reports2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1288Fluoride varnish and dental sealants2013 FormatThe system SHOULD alert when application of fluoride varnish or dental sealant is due. and support management and tracking of this service whether provided by the primary care provider or through a referral.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-883Future dose calculation factors2013 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-1036Gell-Coombs Classification of Hypersensitivity Disorders2013 FormatThe system SHALL support the Gell-Coombs Classification of Hypersensitivity Disorders.Specialized Scales/ScoringNormative Statementsno
Req-676Generate structured clinical and administrative reports2013 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.
Activity Clearance, Well Child/Preventive CareNormative Statementsno
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-1047Gesell Developmental schedules2013 FormatThe system SHALL support the Gesell Developmental schedules.Specialized Scales/ScoringNormative Statementsno
Req-899Gestational age based on Dubowitz or Ballard2013 FormatThe system SHALL record gestational age in weeks based on Dubowitz scoring or Ballard Exam.Birth InformationNormative Statementsno
Req-1019Gestational age estimation2013 FormatThe system SHALL support gestational age estimation based on Ballard Exam or Dubowitz score.Specialized Scales/ScoringNormative Statementsno
Req-898Gestational age in weeks and days2013 FormatThe system SHALL record gestational age in weeks and days based on last menstrual period (LMP ultrasound, or maternal report.Birth InformationNormative Statementsyes
Req-840Growth Charts2013 Format
Anthropometric measures and trends in growth are central to the prevision of pediatric care. Abnormal growth is often the first sign of underlying chronic illness. In addition, body size is necessary for the dosing of...
Anthropometric measures and trends in growth are central to the prevision of pediatric care. Abnormal growth is often the first sign of underlying chronic illness. In addition, body size is necessary for the dosing of most drugs in pediatrics. In general, there are three main direct measures - head circumference, length/height, and weight. Body mass index is calculated based on weight and height.
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Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
Req-126Growth and body composition data2013 FormatSystem supports recording of growth and body composition measures, calculations, conversions, normal ranges, and trending.Growth DataHeaderno
Req-622Growth chart data2013 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 DataNormative Statementsno
Req-844Growth chart magnification2013 FormatFor all growth charts the system SHOULD allow the magnification ("zooming" of the display in order to facilitate understanding of curves where there are many densely-spaced data points.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-1130Guideline based decision support for immunization ordering2013 FormatThe system SHALL provide real-time decision support for ordering immunizations for treatment and prophylaxis (such as tetanus, rabies and hepatitis A/B, etc. based on guidelines.ImmunizationsNormative Statementsno
Req-847Head Circumference2013 FormatHead circumference is typically measured in newborns and then at every well-child visit through 36 months of life. Head circumference may also be measured at other times based on clinician concern, or in cases of chronic neurologic disease or developmental delayChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
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-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-251Health Service Reports at the Conclusion of an Episode of Care2013 Format
STATEMENT: Support the creation of health service reports at the conclusion of an episode of care. Support the creation of health service reports to authorized health entities, for example public health, such as notifiable condition...
STATEMENT: Support the creation of health service reports at the conclusion of an episode of care. Support the creation of health service reports to authorized health entities, for example public health, such as notifiable condition reports, immunization, cancer registry and discharge data that a provider may be required to generate at the conclusion of an episode of care.
DESCRIPTION: Effective use of this function means that providers do not perform additional data entry to support health management programs and reporting.
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Registry LinkagesFunctionno
Req-683Healthcare Resource Availability2013 Format
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In...
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In times of identified local or national emergencies and upon request from authorized bodies, provide current status of healthcare resources including, but not limited to, available beds, providers, support personnel, ancillary care areas and devices, operating theaters, medical supplies, vaccines, and pharmaceuticals. The intent is to enable the authorized body to distribute or re-distribute either resources or patient load to maximize efficient healthcare delivery. In addition, these functions may also be used for internal assessment and planning purposes by facility administrators
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Parents and Guardians and Family Relationship DataFunctionno
Req-869Height Velocity2013 FormatAssessment of a child's growth rate by height.Growth DataFunctionno
Req-628Height input2013 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 DataNormative Statementsno
Req-888High risk drug combinations in children2013 FormatThe system SHALL provide the ability to detect high risk drug combination alerts specific to children and inform the user during ordering.Medication ManagementNormative Statementsyes
Req-580Historical demographic data2013 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.
Child WelfareNormative Statementsno
Req-1278History of Abuse and Neglect2013 FormatHistory of Abuse and NeglectChild Abuse Reporting, Child Welfare, Well Child/Preventive CareFunctionno
Req-1180History of termination of parental rights from an external information source2013 FormatThe system MAY provide the ability to retrieve, capture, store, and display a past history of termination of parental rights from an external information source (e.g. registry for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1179History of termination of parental rights from within EHR2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of termination of parental rights documented within the native EHR system for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1061Hospice and palliative care needs2013 FormatThe system SHALL capture hospice and palliative care needs for the child with identification of age-appropriate resources.Children with Special Healthcare NeedsNormative Statementsno
Req-1147IIS query responses in real-time2013 FormatThe system SHOULD provide the ability to receive real-time electronic query responses from IISs.Immunizations, Registry LinkagesNormative Statementsno
Req-1027INFINIB developmental score2013 FormatThe system SHALL support the infant neurological international battery (INFINIB developmental score.Specialized Scales/ScoringNormative Statementsno
Req-1226Identification of additional births for parents with prior Termination of Parental Rights2013 FormatThe system MAY have the ability to connect with vital records to identify additional births to parents who have had a prior Termination of Parental Rights, when available.Child WelfareNormative Statementsno
Req-679Identify and Maintain a Patient Record2013 Format
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and...
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and linked to the patient record. Static data elements as well as data elements that will change over time are maintained. The patient is uniquely identified, after which the record is tied to that patient. Combining information on the same patient, or separating information where it was inadvertently captured for the wrong patient, helps maintain health information for a single patient. In the process of creating a patient record, it is at times advantageous to replicate identical information across multiple records, so that such data does not have to be re-entered. For example, when a parent registers children as new patients, the address, guarantor, and insurance data may be propagated in the children's records without having to re-enter them.
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Parents and Guardians and Family Relationship DataFunctionno
Req-1082Identify incomplete preventive care opportunities2013 FormatThe system SHALL identify incomplete age-specific screening and preventive care opportunities for each patient scheduled or assigned to a practice (e.g. individual or organizationWell Child/Preventive CareNormative Statementsno
Req-2047Identify incomplete preventive care opportunities2015 Priority ListThe system shall track and report the completion of recommended health supervision visits delivered according to the recommended periodicity of visits included in Bright Futures for a panel of patients.Well Child/Preventive CareNormative Statementyes
Req-1271Identify patient-appropriate questionnaires2013 FormatThe system SHOULD have the ability to identify potentially appropriate patient/caregiver questionnaires based on specific patient parameters such as age or disorder.
Well Child/Preventive CareNormative Statementsno
Req-1132Identify patients underinsured for immunizations2013 FormatThe system SHOULD provide the ability to identify patients who are uninsured or underinsured for immunizations, such as those that are eligible for Vaccines for Children (VFC and S-CHIP/Medicaid.ImmunizationsNormative Statementsno
Req-664Identify recipient-appropriate educational material2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-924Illicit drug use during pregnancy2013 FormatThe system SHALL record other illicit drugs used during pregnancy (Positive, Negative, or Unknown IF positive THEN the system SHALL record the name, dose and frequency of use.Birth InformationNormative Statementsno
Req-120Immediate alerts for abnormal growth values2013 FormatThe system SHALL support alerting at the time of value entry for values outside of the probable range and heights less than previous measures.Growth DataNormative Statementsno
Req-1129Immunity data as vaccine contraindication2013 FormatThe system SHALL provide the ability to link to historical and/or laboratory data that documents a patient's immunity as a contraindication to ordering/administering a vaccine dose.ImmunizationsNormative Statementsno
Req-601Immunization consent status2013 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.
ImmunizationsNormative Statementsno
Req-1104Immunization procurement and inventory management2013 FormatImmunization procurement and inventory managementImmunizationsHeaderno
Req-1148Immunization prompts for patients weighing less than 2 kg2013 FormatIF the patient's weight is below 2 kg, THEN the system SHALL provide the ability to generate a prompt for the immunization prescriber.
ImmunizationsNormative Statementsno
Req-608Immunizations based on risk factors2013 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.
ImmunizationsNormative Statementsno
Req-835Implement age rounding rules2013 Format
The system SHOULD implement age rounding rules that conform to social conventions of age representation
- Age in years, months, weeks, and days should be incremented at the 'day' level of precision, and rounded down...
The system SHOULD implement age rounding rules that conform to social conventions of age representation
- Age in years, months, weeks, and days should be incremented at the 'day' level of precision, and rounded down to an integer
- Age in months should be calculated as though dates that do not exist in a particular month are equivalent to the 1st day of the following month.
- Age in hours and minutes should be incremented at the 'minute' level of precision, and rounded down to an integer
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Well Child/Preventive CareNormative Statementsno
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-1275Import and manage compendia of resources2013 FormatThe system SHOULD have the ability to import and manage compendia of resources for non-medical psychosocial problemsWell Child/Preventive CareNormative Statementsno
Req-2046Import data from pre-visit history/screening/prevention formsWell Child/Preventive Care2015 Priority ListThe system shall allow the asynchronous importation of parent-/patient-derived previsit data in a manner that enables retrieval and reporting.Well Child/Preventive CareNormative Statementyes
Req-1260Import questionnaire results in computable format2013 FormatThe system SHALL be able to import results of questionnaire into a computable format (to the degree that the original responses are computableWell Child/Preventive CareNormative Statementsno
Req-1205Import/export family member demographics2013 FormatThe system SHOULD offer a utility to copy or import and export demographic information between records of parents, guardians, and siblings (including foster siblings within the same home.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1204Import/export family member medical data2013 FormatThe system MAY offer a utility to copy or import and export common medical information, such as family history information, from medical records of biological family members.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-524Incorporate and adhere to legal local and national laws in regards to patient EHR access2013 FormatThe system SHALL incorporate and adhere to local, state, and national laws in regards to patient EHR access (e.g. children under 12 cannot sign up for access to their own accountPatient Portals - PHRNormative Statementsno
Req-2007Incorporate and adhere to local and national laws in regards to patient EHR access2015 Priority List
The system shall provide the ability to apply age-based triggers for Pediatric Patient Portal access to comply with varying Federal, State, and local laws.
• As an example, it is expected that the system will...
The system shall provide the ability to apply age-based triggers for Pediatric Patient Portal access to comply with varying Federal, State, and local laws.
• As an example, it is expected that the system will comply with the Children’s Online Privacy Protection Act.
• The vendor shall identify the States and localities for which the system complies.
• Recommended implementation of this requirement includes line item segmentation of conditions and treatments to allow separation of access between the patient and the parent/guardian.
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Patient Portals - PHRNormative Statementyes
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-485Incorporate scanned documents2013 FormatThe system SHALL provide the ability to incorporate and index scanned documents from internal and external providers or agencies into the patient record.Primary Care ManagementNormative Statementsno
Req-890Indicate common side effects2013 FormatThe system MAY provide the ability to indicate common side effects, including those unique to or more common in children, and inform the user during ordering.Medication ManagementNormative Statementsno
Req-655Indicate formulae for drug dose recommendations2013 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.
Medication ManagementNormative Statementsno
Req-113Indicate information collected at Point of Care2013 FormatThe system SHOULD indicate point of care of collected measures and/or allow filtering of values by point(s of care.Growth DataNormative Statementsno
Req-582Indicate unknown patient gender2013 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.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-902Infant size relative to gestational age2013 FormatThe system SHALL provide the ability to capture, record and store the birth weight, length and head circumference of the infant relative to normal values for its captured and/or assigned gestational age (SGA=Small for Gestational Age, AGA=Appropriate for Gestational Age, LGA=Large for Gestational AgeBirth InformationNormative Statementsno
Req-781Information View2013 Format
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For...
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For example, a nursing supervisor may elect or prefer to see summary data on all patients as the default view.
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Immunizations, Well Child/Preventive CareFunctionno
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
Req-1114Integrate vaccine administration with other systems2013 FormatThe system MAY integrate vaccine dose administration with vaccine/medication management systems and practice management/billing systems.Immunizations, Medication ManagementNormative Statementsno
Req-443Integrated immunizations reporting2013 FormatThe EHR SHOULD allow an integrated view of what immunizations are due or past due.ImmunizationsNormative Statementsno
Req-719Interchange Agreements2013 Format
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION:...
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION: Systems that wish to communicate with each other, must agree on the parameters associated with that information exchange. Interchange Agreements allow an EHR-S to describe those parameters/criteria.
An EHR-S can use the entity registries to determine the security, addressing, and reliability requirements between partners.
An EHR-S can use this information to define how data will be exchanged between the sender and the receiver.
Discovery of interchange services and capabilities can be automatic.
For example:
- A new application can automatically determine a patient demographics source using a Universal Description and Discovery Integration (UDDI for source discovery, and retrieve the Web Services Description Language (WSDL specification for binding details.
- Good Health Hospital is a member of AnyCounty LabNet, for sharing laboratory results with other partners. Good Health Hospital periodically queries LabNet's directory (UDDI to determine if additional information providers have joined LabNet. When new information providers are discovered, the Good Health IT establishes the appropriate service connections based upon the Service Description (WSDL
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ImmunizationsFunctionno
Req-772Interchange Standards Versioning and Maintenance2013 Format
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its...
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its natural update process.

DESCRIPTION:
The life cycle of any given standard results in changes to its requirements. It is critical that an organization know the version of any given standard it uses and what its requirements and capabilities are.

For example, if the organization migrates to an HL7 v2.5 messaging standard, it may choose to take advantage of new capabilities such as specimen or blood bank information. The organization may find that certain fields have been retained for backwards compatibility only or withdrawn altogether. The EHR-S needs to be able to handle all of these possibilities.

Standards typically evolve in such a way as to protect backwards compatibility. On the other hand, sometimes there is little, or no, backwards compatibility when an organization may need to replace an entire standard with a new methodology. An example of this is migrating from HL7 v2 to HL7 v3.

Interchange standards that are backward compatible support exchange among senders and receivers who are using different versions. Version control ensures that those sending information in a later version of a standard consider the difference in information content that can be interchanged effectively with receivers, who are capable of processing only earlier versions. That is, senders need to be aware of the information that receivers are unable to capture and adjust their business processes accordingly.
Version control enables multiple versions of the same interchange standard to exist and be distinctly recognized over time.
Since interchange standards are usually periodically updated, concurrent use of different versions may be required.
Large (and/or federated organizations typically need to use different versions of an interchange standard to meet internal organizational interoperability requirements.
For example, the enterprise-wide standard might use HL7 v2.5 for Lab messages, but some regions of the enterprise might be at a lower level.
It should be possible to retire deprecated interchange standards versions when applicable business cycles are completed while maintaining obsolete versions. An example use of this is for possible claims adjustment throughout the claim's life cycle.
When interchange standards change over time, it is important that retrospective analysis and research correlate and note gaps between the different versions' information structures to support the permanence of concepts over time. An example use of this is the calculation of outcome or performance measures from persisted data stores where one version of a relevant interchange standard, e.g., CDA Release 1 captures the relevant data, e.g., discharge data, differently than CDA Release 2.
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Immunizations, Registry LinkagesFunctionno
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-1025International classification of retinopathy of prematurity (ICROP)2013 FormatThe system SHALL support the international classification of retinopathy of prematurity (ICROPSpecialized Scales/ScoringNormative Statementsno
Req-1023Intra-ventricular hemorrhage scoring2013 FormatThe system SHALL support intra-ventricular hemorrhage scoring.Specialized Scales/ScoringNormative Statementsno
Req-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth InformationNormative Statementsno
Req-1244Legal confidentiality requirements for minors2013 FormatThe system SHALL enable users to implement all applicable confidentiality rules regarding health information of minors; note that these rules exist at more than one level, e.g., National and StateSecurity and ConfidentialityNormative Statementsno
Req-1149Legal constraints on importing maternal data2013 FormatThe system SHALL follow applicable state or federal privacy laws regarding the importation of maternal information into the child's record.Prenatal ScreeningNormative Statementsno
Req-1227Legal history2013 FormatThe system SHOULD have access to the legal history (e.g., first-time offender versus repeat offender, multiple incarcerations when available.Child WelfareNormative Statementsno
Req-1046Leiter International Performance scale2013 FormatThe system SHALL support the Leiter International Performance Scale.Specialized Scales/ScoringNormative Statementsno
Req-851Length/Height2013 FormatLength is typically measured in newborns and then at every well-child visit through 36 months of life. Afterwards, height is typically recorded. Length/height may also be measured at other times based on clinician concern.Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-1270Library of patient/caregiver questionnaires2013 FormatThe system SHOULD have a library of patient/caregiver questionnaires from which clinicians can choose.

Well Child/Preventive CareNormative Statementsno
Req-95Link maternal and birth data to child health record2013 FormatThe system SHALL provide for the linking or recording of maternal and birth data to the child health record. Examples: maternal social history, maternal prenatal results, and gravida/para (GPBirth InformationNormative Statementsno
Req-1005Link maternal and birth data to child health record2013 FormatThe system SHALL provide for the linking of maternal and birth data to the child health record for quality measures. Examples: linkage of frequency of prenatal care to birth weight.Quality MeasuresNormative Statementsyes
Req-2001Link maternal and birth data to child health record2015 Priority ListThe system shall import birth information from an electronic newborn discharge summary as discrete data elements.
All other requirements, such as gestation age, can be incorporated into a birth data elements list.
Birth InformationNormative Statementyes
Req-1111Link patient record to immunization inventory2013 FormatThe system SHOULD provide the ability to link to a vaccine inventory (formulary for information about (immediately available vaccine doses (including brands, products, number of doses, dates of acquisition, and dates of expirationImmunizationsNormative Statementsno
Req-1193Link to Child Welfare registries2013 FormatThe system SHOULD provide an interface or link to child welfare registries to be searchable by name (either child or parent placement, service categories provided, and/or jurisdiction.Child Abuse Reporting, Child Welfare, Registry LinkagesNormative Statementsno
Req-1106Link vaccine dose to patient record2013 FormatThe system SHOULD provide the ability to link each individual vaccine dose/identifier to a specific patient record by patient ID, prescribing provider, planned date of administration, patient insurance , and vaccine identifiers, including type (antigen combination brand, lot number, and dose number.ImmunizationsNormative Statementsno
Req-1105Link vaccine doses to specific patients2013 FormatLink vaccine doses to specific patientsImmunizationsFunctionno
Req-886Liquid drug prescriptions2013 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.
Medication ManagementNormative Statementsno
Req-578Locate records based on previous names2013 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.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1177Maintain unsubstantiated instances of abuse or neglect2013 Format
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability...
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability to expunge or limit communication to certain external systems unsubstantiated instances of abuse or neglect when required by the prevailing law.
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Child Abuse ReportingNormative Statementsno
Req-276Maintenance and Versioning of Standard Terminologies2013 Format
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes,...
STATEMENT: Enable version control according to customized policies to ensure maintenance of utilized standards.
This includes the ability to accommodate changes to terminology sets as the source terminology undergoes its natural update process (new codes, retired codes, redirected codes Such changes need to be cascaded to clinical content embedded in templates, custom formularies, etc., as determined by local policy.
DESCRIPTION: Version control allows for multiple sets or versions of the same terminology to exist and be distinctly recognized over time.
Terminology standards are usually periodically updated, and concurrent use of different versions may be required. Since the meaning of a concept can change over time, it is important that retrospective analysis and research maintains the ability to relate changing conceptual meanings. If the terminology encoding for a concept changes over time, it is also important that retrospective analysis and research can correlate the different encodings to ensure the permanence of the concept. This does not necessarily imply that complete older versions of the terminology be kept in the EHR-S, only access to the changes needs to be maintained.
It should be possible to retire deprecated versions when applicable business cycles are completed while maintaining obsolescent code sets. An example use of this is for possible claims adjustment throughout the claim's lifecycle.
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Special Terminology and InformationFunctionno
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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Functionno
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-256Manage Consents and Authorizations2013 Format
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment...
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
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Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Functionno
Req-1008Manage Data Associated with Breast Milk Storage and Administration2013 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.
Well Child/Preventive CareFunctionno
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-257Manage Immunization Administration2013 Format
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance...
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient's immunization history.
DESCRIPTION: During an encounter, recommendations based on accepted immunization schedules are presented to the provider. Allergen and adverse reaction histories are checked prior to giving the immunization. If an immunization is administered, discrete data elements associated with the immunization including date, type, manufacturer and lot number are recorded. Any new adverse or allergic reactions are noted. If required, a report is made to the public health immunization registry.
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Activity Clearance, EPSDT, Immunizations, Registry LinkagesFunctionno
Req-258Manage Immunization List2013 Format
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured...
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured as discrete data elements including date, type, manufacturer and lot number. The entire immunization history is viewable.
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Activity Clearance, Immunizations, Medication ManagementFunctionno
Req-259Manage Medication List2013 Format
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start,...
STATEMENT: Create and maintain patient-specific medication lists.
DESCRIPTION: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.
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Medication ManagementFunctionno
Req-740Manage Medication Orders2013 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.
Medication ManagementFunctionno
Req-698Manage Non-Medication Patient Care Orders2013 Format
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and...
STATEMENT: Capture and track patient care orders. Enable the origination, documentation, and tracking of non-medication patient care orders.
DESCRIPTION: Non-medication orders that request actions or items can be captured and tracked including new, renewal and discontinue orders. Examples include orders to transfer a patient between units, to ambulate a patient, for medical supplies, durable medical equipment, home IV, and diet or therapy orders.
Each item ordered includes the appropriate detail, such as order identification and instructions. Orders should be communicated to the correct service provider for completion.
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Medication ManagementFunctionno
Req-696Manage Order Sets2013 Format
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease...
STATEMENT: Provide order sets based on provider input or system prompt.
DESCRIPTION: Order sets, which may include medication and non-medication orders, allow a care provider to choose common orders for a particular circumstance or disease state according to standards or other criteria. Recommended order sets may be presented based on patient data or other contexts.
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Well Child/Preventive CareFunctionno
Req-680Manage Orders for Blood Products and Other Biologics2013 Format
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics...
STATEMENT: Communicate with appropriate sources or registries to manage orders for blood products or other biologics.
DESCRIPTION: Interact with a blood bank system or other source to support orders for blood products or other biologics including discontinuance orders. Use of such products in the provision of care is captured. Blood bank or other functionality that may come under jurisdictional law or other regulation (e.g. by the FDA in the United States is not required; functional communication with such a system is required.
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Medication ManagementFunctionno
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-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-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-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
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-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
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-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-264Manage Results2013 Format
STATEMENT: Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
DESCRIPTION: Results of tests are presented in an easily accessible...
STATEMENT: Present, annotate, and route current and historical test results to appropriate providers or patients for review. Provide the ability to filter and compare results.
DESCRIPTION: Results of tests are presented in an easily accessible manner to the appropriate providers. Flow sheets, graphs, or other tools allow care providers to view or uncover trends in test data over time. In addition to making results viewable, it is often necessary to send results to appropriate providers using electronic messaging systems, pagers, or other mechanisms. Documentation of notification is accommodated. Results may also be routed to patients electronically or by letter.
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Primary Care ManagementFunctionno
Req-767Manage Structured Health Record Information2013 Format
STATEMENT: Create, capture, and maintain structured health record information.

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

Examples of structured health information include:
-...
STATEMENT: Create, capture, and maintain structured health record information.

DESCRIPTION: 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 EHRS (e.g., Subjective/Objective/Assessment/Plan but unstructured in others.
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Well Child/Preventive CareFunctionno
Req-1211Manage child’s health history2013 FormatThe system SHALL provide the ability to access, capture, store, display, and manage a child's health history including medication lists, medication allergies, adverse reactions, and immunizations.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1009Manage data associated with breast milk products2013 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.
Well Child/Preventive CareNormative Statementsno
Req-1118Manage immunization data for quality measures2013 FormatThe system SHALL provide the ability to manage (search, retrieve, display, sort/filter, calculate immunization data to determine immunization rates (and other quality measures for practices and subsets (by provider, by care group, by patient population, age groups, etc.ImmunizationsNormative Statementsno
Req-1109Manage immunization inventory2013 FormatManage immunization inventoryImmunizationsFunctionno
Req-1058Manage language preferences2013 FormatThe system SHALL capture the child's preferred language, including sign language (separately from that of the parent/caregiver and whether an interpreter is necessary.Children with Special Healthcare NeedsNormative Statementsno
Req-1207Manage progress summaries, assessments, and service plans2013 FormatThe system SHOULD retrieve, capture, store, and display a child's progress summaries, assessments, and service plans.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1257Manage results of questionnaires2013 FormatThe system SHALL have the ability to send, score, and support the results of questionnaires in a variety of formats, including web-based, paper, and telephone-based.Well Child/Preventive CareNormative Statementsno
Req-1178Manage roles and permissions for child abuse data2013 FormatThe system SHOULD provide the ability to define and manage roles and permissions to access specific sections of the system with role-based access including, but not limited to, access to child abuse data by child welfare agents and physicians.Child Abuse ReportingNormative Statementsno
Req-1151Manually import maternal data into patient history2013 FormatWhen electronic access to the mother's data is not possible, the system SHOULD enable incorporation of selected maternal prenatal and perinatal data by manual entry into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-665Mask selected EHR data2013 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.
Security and ConfidentialityNormative Statementsyes
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-1154Maternal Group B strep status2013 FormatThe system SHALL capture maternal Group B strep status and prophylaxis according to current guidelines from the CDC into the child's chart.Prenatal ScreeningNormative Statementsno
Req-912Maternal HIV status2013 FormatThe system SHALL record maternal HIV status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-911Maternal VDRL status2013 FormatThe system SHALL record maternal syphilis status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-1156Maternal blood type2013 FormatThe system SHALL capture maternal blood type including Rh factor in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative Statementsno
Req-915Maternal chlamydia status2013 FormatThe system SHALL record maternal chlamydia Status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-925Maternal drug screening results2013 FormatThe system SHALL record drug screening results including drug tested and results (Positive, Negative, or UnknownBirth InformationNormative Statementsno
Req-914Maternal gonorrhea status2013 FormatThe system SHALL record maternal gonorrhea status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-910Maternal hepatitis B status2013 FormatThe system SHALL record maternal hepatitis B status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-1155Maternal infections that impact the newborn2013 FormatThe system SHALL capture other maternal infections that can affect the newborn in a manner consistent with standard coding (e.g., SNOMED-CT into the child's chart.Prenatal ScreeningNormative Statementsno
Req-908Maternal rubella status2013 FormatThe system SHALL record maternal rubella status as Immune, Non-Immune or Unknown.Birth InformationNormative Statementsno
Req-909Maternal sickle cell status2013 FormatThe system SHALL record maternal sickle cell status as HbSS, HbSC, HbS-Thal, Negative or Unknown.Birth InformationNormative Statementsno
Req-917Maternal substance abuse and social history2013 FormatMaternal social history and history of substance abuse can have a dramatic impact on the care of a newborn infant.Birth InformationFunctionno
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-1243Maximum pediatric daily dose2013 FormatIF the maximum daily dose or maximum pediatric daily dose is known, then the system SHALL apply the lesser of the two in dosing decision support.Medication ManagementNormative Statementsno
Req-852Measure length/height precisely2013 FormatThe system SHALL record length/height at least to the half centimeter, or quarter inch, based on user preference, whether the measure was length or height, and record the date of measure.Growth Data, Well Child/Preventive CareNormative Statementsno
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-577Measurement, Monitoring, and Analysis2013 FormatSTATEMENT: Support measurement and monitoring of care for relevant purposesChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-523Measures to verify identity of parent/guardian2013 FormatThe system SHOULD incorporate measures that confirm/verify the identity of the parent/s or guardian/s and their relationship to a child.Patient Portals - PHRNormative Statementsno
Req-1230Medicaid case number2013 FormatThe system SHALL have the ability to store, retrieve, and display information about the child's Medicaid case number.Child WelfareNormative Statementsno
Req-686Medication administration details2013 FormatThe system SHALL provide the ability to capture all pertinent details of the medication administration including medication name, strength, dose, route, time of administration, exceptions to administration, and administrator of the medication.Medication ManagementNormative Statementsno
Req-293Medication and Immunization Management2013 FormatSystem manages Medications and ImmunizationsImmunizations, Medication Management, Registry LinkagesHeaderno
Req-926Medication use during pregnancy2013 FormatPrescribed medications taken during pregnancy or near the time of birth are important for the care of a newborn infant.Birth InformationFunctionno
Req-1191Mental health, learning, and developmental history2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's developmental stage, learning barriers, mental health history, and current therapy related to development, learning, or mental health/substance abuse (e.g., speech therapy, cognitive therapy, and antidepressantsChild Abuse Reporting, EPSDT, Well Child/Preventive CareNormative Statementsno
Req-624Mid-parental height2013 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 DataNormative Statementsno
Req-1266Milestone Questionnaires2013 FormatDecision support for age-appropriate administration of milestone questionnaires.Well Child/Preventive CareFunctionno
Req-1068Minimum required data in summary2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1024Modified Bell Staging Criteria2013 FormatThe system SHALL support the Modified Bell Staging Criteria for necrotizing enterocolitis.Specialized 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.
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Specialized Scales/ScoringNormative Statementsno
Req-973Monitor compliance with recommended periodicity of visits2013 FormatThe system SHALL monitor and report on compliance with the recommended locally adopted periodicity of visits and be able to identify individuals who have not attended recommended health supervision visits.Well Child/Preventive CareNormative Statementsyes
Req-662Multilingual educational material2013 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.
Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1245Multiple and flexible models of consent2013 FormatMultiple and flexible models of consentSecurity and ConfidentialityFunctionno
Req-542Multiple terminology versioning2013 FormatThe system SHALL provide the ability to use different versions of terminology standards, (e.g. a child-specific version, when it existsSpecial Terminology and InformationNormative Statementsno
Req-1233Multiple units of measurement2013 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 Management, Well Child/Preventive CareNormative Statementsno
Req-1098Multiple views of child data2013 Format
The system SHALL provide multiple views of the child's data, including views for patients and adult caregivers.
Example: The system may have multiple views of the same data, e.g., a clinician view, an adult caregiver...
The system SHALL provide multiple views of the child's data, including views for patients and adult caregivers.
Example: The system may have multiple views of the same data, e.g., a clinician view, an adult caregiver view, and a child view. The data in the source system (EHR must be structured in a manner that permits parents and caregivers to view and understand the extent to which the care their children receive is clinically appropriate and of high quality.
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Patient Portals - PHRNormative Statementsno
Req-1119Multiple views of the immunization record2013 FormatThe system SHOULD provide the ability to display different views of a patient's immunization records, allowing users to specify data fields in the view.ImmunizationsNormative Statementsno
Req-1021N-PASS Neonatal Pain Scale2013 FormatThe system SHALL support the N-PASS Neonatal Pain Scale.Specialized Scales/ScoringNormative Statementsno
Req-955Na-bicarbonate in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of sodium bicarbonate used during resuscitation.Birth InformationNormative Statementsno
Req-922Narcotics use during pregnancy2013 FormatThe system SHALL record narcotics use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of narcotics used per day.Birth InformationNormative Statementsno
Req-1167National guidelines for disease-specific management2013 FormatThe system SHOULD incorporate national guidelines for disease-specific management and allow update, e.g. for shared-decision-making (SDM national guidelines for patients with attention deficit hyperactive disorder (ADHD and asthma diagnosis and management for pediatric patients.Primary Care ManagementNormative Statementsno
Req-1203Navigate between family member charts2013 FormatThe system SHOULD provide a feature to navigate easily between related charts of biological family members (such as mother/baby, parent/child, and siblings without dependence on matching surnames.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-948Neonatal Resuscitation2013 FormatResuscitation is common in the delivery room and the steps taken must be documented as part of the record.Birth InformationFunctionno
Req-947Neonatal physical exam2013 FormatThe system SHALL record the physical exam of the neonate.Birth InformationNormative Statementsno
Req-90Neonatal screening education2013 FormatThe system SHOULD provide prompting, documentation of teaching, and education materials about neonatal screening for parents and guardians.Newborn ScreeningNormative Statementsno
Req-613New results notification2013 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.
Primary Care ManagementNormative Statementsno
Req-1146Newborn Screening - Testing2013 Format
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried...
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried blood spot analysis by state public health departments. More recently, point-of-service testing in the nursery (e.g., newborn hearing screening has been included. Another point-of-service test that will likely be added to newborn screening is pulse oximetry to detect critical cyanotic congenital heart disease. Newborn screening is expanding at a rapid rate. Although the US Secretary of Health and Human Services makes recommendations about what should be included as part of newborn screening, individual states are responsible for developing their own panel, including the threshold for a positive test. Some states require retesting of all newborns. States have varying methods of short and long-term follow-up for those that have tested positive. Some parents may choose to have supplemental newborn screening through private laboratories. This is outside of the scope of these requirements.
ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at:http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf. The U.S. National Library of Medicine (NLM has published the Newborn Screening Coding and Terminology to promote and facilitate the use of electronic health data standards for the conditions recommended for screening by the HHS Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC This is available at: http://newbornscreeningcodes.nlm.nih.gov/.
The National Newborn Screening and Genetics Resource Center (http://genes-r-us.uthscsa.edu/ provides continuously updated information on the conditions screened for in each state. In addition, links are available to each state program. The Resource Center also provides educational material for clinicians and family members.
Well-described clinical algorithms have been developed to guide general pediatricians and subspecialists in the process of newborn screening. These are available at:http://pediatrics.aappublications.org/content/121/1/192.abstract. The requirements were designed to support these algorithms. In addition, these requirements support the transition from diagnosis through screening to chronic condition management and long-term follow-up as described in Kemper AR, Boyle CA, Aceves J, et al. Long-term follow-up after diagnosis resulting from newborn screening: statement of the US Secretary of Health and Human Services' Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Genet Med. 2008:10:259-261.
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Newborn ScreeningHeaderno
Req-823Newborn Screening Decision Support2013 Format

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf [1]. The U.S. National...

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf [1]. The U.S. National Library of Medicine (NLM has published the Newborn Screening Coding and Terminology to promote and facilitate the use of electronic health data standards for the conditions recommended for screening by the HHS Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC This is available at: http://newbornscreeningcodes.nlm.nih.gov/ [2].

The National Newborn Screening and Genetics Resource Center (http://genes-r-us.uthscsa.edu/ [3] provides continuously updated information on the conditions screened for in each state. In addition, links are available to each state program. The Resource Center also provides educational materials for clinicians and family members.
Well-described clinical algorithms have been developed to guide general pediatricians and subspecialists in the process of newborn screening. These are available at: http://pediatrics.aappublications.org/content/121/1/192.abstract[4]. Exit Disclaimer The requirements were designed to support these algorithms. In addition, these requirements support the transition from diagnosis through screening to chronic condition management and long-term follow-up as described in Kemper AR, Boyle CA, Aceves J, et al. Long-term follow-up after diagnosis resulting from newborn screening: statement of the US Secretary of Health and Human Services' Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Genet Med. 2008:10:259-261

Links:
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[1] http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf
[2] http://newbornscreeningcodes.nlm.nih.gov/
[3] http://genes-r-us.uthscsa.edu/ Exit Disclaimer
[4] http://pediatrics.aappublications.org/content/121/1/192.abstract Exit Disclaimer
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Newborn ScreeningHeaderno
Req-822Newborn Screening Follow-Up2013 Format
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried...
The goal of newborn screening is to identify a wide range of conditions that can potentially benefit from early detection during the presymptomatic or early symptomatic period. Historically, newborn screening has been based on dried blood spot analysis by state public health departments. More recently, point-of-service testing in the nursery (e.g., newborn hearing screening has been included. Another point-of-service test that will likely be added in the coming year to newborn screening is pulse oximetry to detect critical cyanotic congenital heart disease. Newborn screening is expanding at a rapid rate. Although the US Secretary of Health and Human Services makes recommendations about what should be included as part of newborn screening, individual states are responsible for developing their own panel, including the threshold for a positive test. Some states require retesting of all newborns. States have varying methods of short and long-term follow-up for those that have tested positive. Some parents may choose to have supplemental newborn screening through private laboratories. This is outside of the scope of this requirement statement.

ONC and HRSA are actively developing use cases and other health IT resources around newborn screening. A use case is available at: http://www.hhs.gov/healthit/usecases/documents/NBSDetailedUseCase.pdf. The U.S. National Library of Medicine (NLM has published the Newborn Screening Coding and Terminology to promote and facilitate the use of electronic health data standards for the conditions recommended for screening by the HHS Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC This is available at: http://newbornscreeningcodes.nlm.nih.gov/.

The National Newborn Screening and Genetics Resource Center (http://genes-r-us.uthscsa.edu/ provides continuously updated information on the conditions screened for in each state. In addition, links are available to each state program. The Resource Center also provides educational material for clinicians and family members.
Well-described clinical algorithms have been developed to guide general pediatricians and subspecialists in the process of newborn screening. These are available at: http://pediatrics.aappublications.org/content/121/1/192.abstract. Exit Disclaimer The requirements were designed to support these algorithms. In addition, these requirements support the transition from diagnosis through screening to chronic condition management and long-term follow-up as described in Kemper AR, Boyle CA, Aceves J, et al. Long-term follow-up after diagnosis resulting from newborn screening: statement of the US Secretary of Health and Human Services' Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Genet Med. 2008:10:259-261.
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Newborn ScreeningHeaderno
Req-800Newborn dried blood spot collection time and state2013 Format
The system SHALL record the state and collection date and time with precision no less than the nearest clock hour for when each newborn screening dried blood spot was collected. Multiple samples at multiple times...
The system SHALL record the state and collection date and time with precision no less than the nearest clock hour for when each newborn screening dried blood spot was collected. Multiple samples at multiple times may be collected, such as in those states that require repeat testing or on prematurely born neonates.
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Newborn ScreeningNormative Statementsno
Req-2015Newborn dried blood spot collection time and state2015 Priority List
The system where the blood spot test was performed shall record the State and collection date and time with precision to no less than the nearest clock hour for when each newborn screening dried blood...
The system where the blood spot test was performed shall record the State and collection date and time with precision to no less than the nearest clock hour for when each newborn screening dried blood spot was collected. Multiple samples at multiple times may be collected, such as in States that require repeat testing or on prematurely born neonates.
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Newborn ScreeningNormative Statementyes
Req-575Non-Medication Orders and Referrals Management2013 FormatManage Non-Medication Orders and ReferralsMedication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-629Normal data range per Tanner stage2013 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 DataNormative Statementsno
Req-1076Normal data ranges2013 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.
Well Child/Preventive CareNormative Statementsno
Req-953Normal saline in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of normal saline solution used during resuscitation.Birth InformationNormative Statementsno
Req-112Normative values for growth chart data2013 FormatThe system SHOULD calculate and display average weight for age, average height for age, and ideal/target weight for height (e.g. Waterlow methodGrowth DataNormative Statementsno
Req-1087Notification routing2013 FormatThe system SHALL direct notifications to authorized, appropriate recipients.Well Child/Preventive CareNormative Statementsno
Req-1181Notification to child welfare per mandate2013 Format
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as...
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as state, tribal or other authority that child welfare be notified in instances of abuse that includes a past history of termination of parental rights.
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Child Abuse ReportingNormative Statementsno
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-99Nutritional status analysis2013 FormatThe system SHOULD allow for nutritional status analysis during activity clearance examinations.Activity ClearanceNormative Statementsno
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-607Order blood products in pediatric units2013 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.
Medication ManagementNormative Statementsno
Req-2010Order blood products in pediatric units2015 Priority List
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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.
Medication ManagementNormative Statementyes
Req-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
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-1272Organization of imported psychosocial and case management information2013 FormatThe system SHOULD support the detailed organization of psychosocial and case management information that originates external to the EHR.Well Child/Preventive CareNormative Statementsno
Req-1223Out-of-home care history2013 FormatThe system SHALL have the ability to store, retrieve, and display whether the child has ever been in out-of-home care (yes or no is sufficientChild WelfareNormative Statementsno
Req-571Outcome Measures and Analysis2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary for the reporting on patient outcome of care by population, facility, provider or community.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. The system needs to provide the report generating capability to easily create these reports or provide for the export of data to external report generating software. The system may also provide the functionality to prompt for the collection of necessary information at the appropriate time in a patient encounter if such collection need can be properly defined in a supportive workflow.
e.g. Requesting specific information for reporting of emergency services such as gun shot, suspected abuse, communicable diseases etc., or for the collection of additional research data for specific a specific diagnosis.
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Well Child/Preventive CareFunctionno
Req-944Oxygen saturation in delivery room2013 FormatThe system SHALL record percutaneous oxygen saturation measurements in the delivery room.Birth InformationNormative Statementsno
Req-1041PEDS screen2013 FormatThe system SHALL support the PEDS screen.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-1176Past history of abuse and neglect by perpetrator2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect by the alleged perpetrator.Child Abuse ReportingNormative Statementsno
Req-1175Past history of abuse and neglect for the child2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect for the child.Child Abuse ReportingNormative Statementsno
Req-574Patient Access Management2013 Format
STATEMENT: Enable a healthcare delivery organization to allow and manage a patient's access to the patient's personal health information.
DESCRIPTION: A healthcare delivery organization will be able to manage a patient's ability to view his...
STATEMENT: Enable a healthcare delivery organization to allow and manage a patient's access to the patient's personal health information.
DESCRIPTION: A healthcare delivery organization will be able to manage a patient's ability to view his or her EHR based on scope of practice, organization policy or jurisdictional law. Typically, a patient has the right to view his or her EHR and the right to place restrictions on who can view parts or the whole of that EHR. For example, in some jurisdictions, minors have the right to restrict access to their data by parents/guardians.
One example of managing a patient's access to his or her data is by extending user access controls to patients.
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Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityFunctionno
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-274Patient Privacy and Confidentiality2013 Format
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of...
STATEMENT: Enable the enforcement of the applicable jurisdictional and organizational patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.
DESCRIPTION: Patients' privacy and the confidentiality of EHRs are violated if access to EHRs occurs without authorization. Violations or potential violations can impose tangible economic or social losses on affected patients, as well as less tangible feelings of vulnerability and pain. Fear of potential violations discourages patients from revealing sensitive personal information that may be relevant to diagnostic and treatment services. Rules for the protection of privacy and confidentiality may vary depending upon the vulnerability of patients and the sensitivity of records. Strongest protections should apply to the records of minors and the records of patients with stigmatized conditions. Authorization to access the most sensitive parts of an EHR is most definitive if made by the explicit and specific consent of the patient. Please see the definition of masking in the glossary.
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Patient Identifier, Prenatal Screening, Security and ConfidentialityFunctionno
Req-721Patient Reminder Information Updates2013 Format
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health...
STATEMENT: Receive and validate formatted inbound communications to facilitate updating of patient reminder information from external sources such as Cancer or Immunization Registries.

DESCRIPTION: Information from outside groups, such as immunization groups, public health organizations, etc. may periodically send updates to patient care providers. The system should be capable of generating patient reminders based on the recommendations of these organizations. Patient reminders could be provided to patients by a number of means including phone calls, or mail. A record of such reminders may become part of a patient's record. Examples of reminders could include a recommended immunization, prophylactic guidelines for MVP, patient self-testing for disease, etc.
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Well Child/Preventive CareFunctionno
Req-832Patient age in units appropriate to environment of care2013 FormatThe system SHALL present patient age using units appropriate to the environment of care as well as the patient age.Well Child/Preventive CareNormative Statementsyes
Req-1097Patient and Caregiver Views2013 FormatThe child's clinical information should be accessible by the child, parents, guardians, caregivers and other consumers to enable assessment of compliance with school or leisure activity requirements. In addition, it should be usable by caregivers to assure care appropriateness and quality.Immunizations, Patient Portals - PHRFunctionno
Req-1173Patient education at transition to adult care2013 FormatThe system SHOULD support patient education that occurs at the transition of care from pediatric to adult care.Primary Care ManagementNormative Statementsno
Req-674Patient indicators on reports2013 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.
Patient IdentifierNormative Statementsno
Req-1093Patient reminders to appropriate preventive care recipient2013 FormatThe system SHOULD deliver patient reminders to an appropriate recipient for preventive care, where the recipient selection varies by age and personal circumstances.Well Child/Preventive CareNormative Statementsno
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-633Patient-milk product matching2013 Format
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