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Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
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-2028Use established immunization messaging standards2015 Priority List
A The system shall use the messaging standards established through Meaningful Use requirements to send data to Immunization Information Systems (IISs or other Health Information Exchanges (HIEs
B The system shall use the messaging standards...
A The system shall use the messaging standards established through Meaningful Use requirements to send data to Immunization Information Systems (IISs or other Health Information Exchanges (HIEs
B The system shall use the messaging standards established through Meaningful Use requirements to receive data from Immunization Information Systems (IISs or other Health Information Exchanges (HIEs
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Immunizations, Registry LinkagesNormative Statementyes
Req-1094Personal Health Record Access2013 Format
A personal health record (PHR for children is a significantly complex issue, but one that must have a perfunctory overview in the child EHR specifications. The PHR allows a person, in this case child or...
A personal health record (PHR for children is a significantly complex issue, but one that must have a perfunctory overview in the child EHR specifications. The PHR allows a person, in this case child or parent, to view their clinical history as aggregated from many sources and must be compliant with the appropriate statutes (federal, state and local In addition to the viewing of their history, users of a PHR can enter their own data as they deem pertinent. These data can range from social history to over the counter medications.

The PHR should be accessible by the child, parents, guardians, caregivers and other consumers to enable assessment of compliance with school or leisure activity requirements. This multiple person access requirements must be managed within legal and appropriate security constraints.
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Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityFunctionno
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-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-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-869Height Velocity2013 FormatAssessment of a child's growth rate by height.Growth DataFunctionno
Req-129Present Alerts for Preventive Services and Wellness2013 Format
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider...
At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.
At the time of an encounter, the provider or patient is presented with due or overdue activities based on protocols for preventive care and wellness. Examples include but are not limited to, routine immunizations, adult and well child care, age and gender appropriate screening exams, such as PAP smears. The provider may wish to provide reminders to the patient based on the alert.
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EPSDT, Newborn Screening, Well Child/Preventive CareFunctionno
Req-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-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-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-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-455Sport/Activity Clearances2013 Format
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should...
DESCRIPTION: Activity Clearances are a review of systems conducted to facilitate a child's participation in extracurricular activities such as camps, sports teams or lessons, dance or gymnastic lessons, and/or student travel. The Activity Clearance should not be confused with a well-child physical examination conducted for the purpose of establishing a patient's health status nor should it be confused with the inpatient examination, assessment, or history and physical. Elements of the Activity Clearance may be specific to the requesting entity (e.g. a school district or the requesting entity may provide a specific form for the clinician to report his or her findings. Alternate names for these types of examinations include: Sports Qualifying Examinations, Clearance forms, and Pre-participation screens.
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Activity Clearance, Well Child/Preventive CareHeaderno
Req-279Support Clinical Communication2013 Format
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs...
DESCRIPTION: Healthcare requires secure communications among various participants: patients, doctors, nurses, chronic disease care managers, pharmacies, laboratories, payers, consultants, and etcetera. An effective EHRS supports communication across all relevant participants, reduces the overhead and costs of healthcare-related communications, and provides automatic tracking and reporting. The list of communication participants is determined by the care setting and may change over time. Because of concerns about scalability of the specification over time, communication participants for all care settings or across care settings are not enumerated here because it would limit the possibilities available to each care setting and implementation. However, communication between providers and between patients and providers will be supported in all appropriate care settings and across care settings. Implementation of the EHRS enables new and more effective channels of communication, significantly improving efficiency and patient care. The communication functions of the EHRS will eventually change the way participants collaborate and distribute the work of patient care.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-877Editing of Data2013 FormatData editing aspects of the system.Growth DataFunctionno
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-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-1266Milestone Questionnaires2013 FormatDecision support for age-appropriate administration of milestone questionnaires.Well Child/Preventive CareFunctionno
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-1040Developmental Scores / Intelligence Tests2013 FormatDevelopmental scores and scales are critical to assessing developmental milestones.Specialized Scales/ScoringFunctionno
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-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-846Support display of normative curves in standard deviations2013 FormatFor all curves described here, the system MAY provide views of normative curves in standard deviations to allow for the interpretation of more extreme measurements (e.g., charts for very obese children where all measurements are >95th percentileGrowth DataNormative Statementsno
Req-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-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-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-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-106Record Management2013 Format
For those functions related to data capture, data may be captured using standardized code sets or nomenclature, depending on the nature of the data, or captured as unstructured data. Care-setting dependent data is entered by...
For those functions related to data capture, data may be captured using standardized code sets or nomenclature, depending on the nature of the data, or captured as unstructured data. Care-setting dependent data is entered by a variety of caregivers. Details of who entered data and when it was captured should be tracked. Data may also be captured from devices or other tele-health applications.
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Birth Information, Child Welfare, Genetic information, Growth Data, Immunizations, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals...
Birth Information, Child Welfare, Genetic information, Growth Data, Immunizations, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, Primary Care Management, Well Child/Preventive Care
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Headerno
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-1278History of Abuse and Neglect2013 FormatHistory of Abuse and NeglectChild Abuse Reporting, Child Welfare, Well Child/Preventive CareFunctionno
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-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-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-684Propagate identical data for related patients2013 FormatIF related patients register with any identical data, THEN the system SHOULD provide the ability to propagate that data to all their records.Parents and Guardians and Family Relationship DataNormative 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-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-1145Report adverse immunization events per legal requirements2013 FormatIF the system has the capacity to prepare reports of patient adverse events due to immunizations, THEN the system SHALL prepare the report according to the requirements of local, state and federal agencies as specified by law.Immunizations, Registry LinkagesNormative Statementsno
Req-1112Update immunization inventory on vaccine dose administration2013 FormatIF the system links to a vaccine inventory (formulary THEN the system SHOULD update the inventory/formulary when a vaccine dose is administered and documented.ImmunizationsNormative 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-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-124Support for Identification of Potential Problems and Trends2013 Format
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab...
Identify trends that may lead to significant problems, and provide prompts for consideration.
When personal health information is collected directly during a patient visit, input by the patient, or acquired from an external source (lab results it is important to be able to identify potential problems and trends that may be patient-specific, given the individual's personal health profile, or changes warranting further assessment. For example: significant trends (lab results, weight a decrease in creatinine clearance for a patient on metformin, an abnormal increase in INR for a patient on warfarin, an increase in suicidal ideation; presence of methamphetamines; or absence of therapeutic levels of antidepressants.
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Well Child/Preventive CareFunctionno
Req-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-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-655Indicate formulae for drug dose recommendations2013 Format
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Medication ManagementNormative Statementsno
Req-1104Immunization procurement and inventory management2013 FormatImmunization procurement and inventory managementImmunizationsHeaderno
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-513Retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the victim, teen pregnancy and births.2013 FormatIn cases of child abuse the system SHOULD provide the ability to retrieve, capture, store, and display information regarding age of menarche, past sexual activity of the patient, teen pregnancy and births.Child Abuse Reporting, Well Child/Preventive CareNormative Statementsno
Req-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
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