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Req-1012Standard terminology for diagnoses2013 FormatThe system SHOULD provide the ability to encode diagnoses using a terminology identified as an adequate standard for documenting diagnoses common in childhood.Special Terminology and InformationNormative Statementsno
Req-1014Standard terminology for signs, systems, and development2013 FormatThe system SHOULD provide the ability to encode pediatric signs, symptoms and development using a terminology identified as a standard for documenting signs and symptoms.Special Terminology and InformationNormative Statementsno
Req-1015Standard terminology for laboratory testing2013 Format
The system SHOULD provide the ability to encode laboratory and other testing names common to children using a terminology identified as a standard for documenting laboratory names .
Comment: In some cases, laboratory and other...
The system SHOULD provide the ability to encode laboratory and other testing names common to children using a terminology identified as a standard for documenting laboratory names .
Comment: In some cases, laboratory and other testing is managed by a laboratory information system that is either a component of or external to the EHR system. In those cases, the laboratory information system can use the terminology identified as a standard for documenting laboratory and testing names. In other cases, results from laboratory and other testing is entered directly into the EHR system by a healthcare provider. For example, office-based testing for streptococcus, pregnancy or infectious mononucleosis typically would not be documented in a laboratory information system. A user may prefer not to provide the terminology mapping to a specific vocabulary; however the EHR system may have this already linked in their system.
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Special Terminology and InformationNormative 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-2038Separate consent, assent and permission2015 Priority ListThe system shall support the recording of consent, assent, and permission as separate artifacts.Security and Confidentiality, Parents and Guardians and Family Relationship DataNormative Statementyes
Req-550Support patient consent requirements based on law2013 FormatThe system SHOULD determine the need for minor patient consent based on determination of age of majority based on jurisdictional law.Security and ConfidentialityNormative Statementsno
Req-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-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-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-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-590Document assent for patients unable to consent2013 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 Statementsno
Req-671Define formal health record2013 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 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-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-1245Multiple and flexible models of consent2013 FormatMultiple and flexible models of consentSecurity and ConfidentialityFunctionno
Req-1246Separate consent, assent and permission2013 FormatThe system SHALL support the recording of consent, assent, and permission as separate artifacts.Security and ConfidentialityNormative 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-1254Segmented access to information2013 FormatThe system SHALL have the ability to segment health care data and provide views of the record that correspond to granular authorizations as to data-type, user, and/or purpose, as provided by the parent/guardian and/or the minor, as relevant.Security and ConfidentialityNormative Statementsno
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-1252User guidance based on age of consent2013 FormatThe system MAY provide user guidance based on patient age for consent and assent according to organizational policy or jurisdictional law.Security and ConfidentialityNormative Statementsno
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-1250Age of emancipation2013 FormatThe system SHOULD record the patient's age of emancipation.Security and ConfidentialityNormative Statementsno
Req-1249Problem-specific age of consent2013 FormatThe system SHALL record the age of consent for specific problems and/or diagnosis.Security and ConfidentialityNormative Statementsno
Req-1248Time stamp consent to guardianship2013 FormatThe system SHOULD record the date and time of consent to guardianship when transferred from biological relationship, e.g., mother, father, or kinships, foster or custodial care, or proxy.Security and ConfidentialityNormative Statementsno
Req-1212Document decision-making authority of patient representative2013 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 Statementsno
Req-2030Document decision-making authority of patient representative2015 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.
Security and ConfidentialityNormative Statementyes
Req-2039Problem-specific age of consent2015 Priority ListThe system shall provide the ability to access legal guidelines on consent requirements for reference, where available, and to record the age of consent for a specific treatment when these differ based on legal guidelines.Security and ConfidentialityNormative Statementyes
Req-2040Age of emancipation2015 Priority ListThe system shall provide the ability to record the patient's emancipated minor status.Security and ConfidentialityNormative Statementyes
Req-2041Segmented access to information2015 Priority ListThe system shall provide users the ability to segment health care data in order to keep information about minor consent services private and distinct from other content of the record, such that it is not exposed to parents/guardians without the minor’s authorization.Security and ConfidentialityNormative Statementyes
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-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-1054FERPA compliance2013 FormatThe system SHALL comply with Family Educational Rights and Privacy Act (FERPA rules.School-Based 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-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-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-546Support ability to export data for non-interfaced registries2013 FormatThe system SHALL provide user controlled export features such as protected text or data files for registries that can't or won't accept interfaced or service fed data.Registry LinkagesNormative Statementsno
Req-547Support the tracking of the release of information to outside registries through linkage mechanisms2013 Format
The system SHALL provide data elements that support the tracking of the release of information to outside registries through linkage mechanisms. Release tracking must cascade to the patient level (X patient's data linked to Y...
The system SHALL provide data elements that support the tracking of the release of information to outside registries through linkage mechanisms. Release tracking must cascade to the patient level (X patient's data linked to Y registry. Data elements: Releasing System, Receiving System, Date and Time of Release, Releasing Agent, Reason for Release, Trust Relationship, Release Mechanism.
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Registry 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-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-677Service 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.
Registry LinkagesNormative Statementsyes
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-566Performance and Accountability Measures2013 Format
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting...
STATEMENT: Support the capture and subsequent export or retrieval of data necessary to provide quality, performance, and accountability measurements which providers, facilities, delivery systems, and communities are held accountable.
DESCRIPTION: Many regions require regular reporting on the healthcare provided to individuals and populations. These reports may include measures related to process, outcomes, costs of care, may be used in 'pay for performance' monitoring and adherence to best practice guidelines. 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.
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Quality MeasuresFunctionno
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-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-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-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-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-267Produce a Summary Record of Care2013 Format
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of...
STATEMENT: Present a summarized review of a patient's comprehensive EHR, subject to jurisdictional laws and organizational policies related to privacy and confidentiality.
DESCRIPTION: Create summary views and reports at the conclusion of an episode of care. Create service reports at the completion of an episode of care such as, but not limited to, discharge summaries and public health reports, without additional input from clinicians.
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Primary Care Management, Well Child/Preventive CareFunctionno
Req-569Support for Non-Medication Ordering2013 Format
STATEMENT: Display and request provider validation of information necessary for non-medication orders that make the order pertinent, relevant and resource-conservative at the time of provider order entry.

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

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

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