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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-1213Distinguish guardian from guarantor2013 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-89Prompts for local neonatal screening2013 FormatThe system SHALL have the ability to prompt the care provider to perform all locally required neonatal screening tests.Newborn ScreeningNormative 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-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-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-818Support appropriate newborn screening and follow-up2013 FormatThe system SHALL incorporate the algorithms described in http://pediatrics.aappublications.org/content/121/1/192.abstract Exit Disclaimer to assure screening has been accomplished and that results have been followed up.Newborn ScreeningNormative Statementsno
Req-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-801Record time when mandated point-of-service testing occurred2013 Format
The system SHALL record the date and time with precision no less than the nearest clock hour when a mandated non-blood spot newborn screening occurred, as well as the specific modality and the results of...
The system SHALL record the date and time with precision no less than the nearest clock hour when a mandated non-blood spot newborn screening occurred, as well as the specific modality and the results of the screen using standard codified terms (e.g., SNOMED-CT Presently, this is only newborn hearing screening. Multiple screenings at multiple times may occur.
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Newborn ScreeningNormative Statementsno
Req-802Record refusal of newborn dried blood spot testing2013 FormatThe system SHALL capture refusal of newborn dried blood spot if such screening is refused by the child's legal guardian.Newborn ScreeningNormative Statementsno
Req-803Record refusal of point-of-service testing2013 FormatThe system SHALL capture refusal of non-blood spot newborn screening (e.g., newborn hearing screening if such screening is refused by the child's legal guardian.Newborn ScreeningNormative Statementsno
Req-812Record reporting of newborn screening results to the state health department2013 FormatThe system SHALL record that the diagnosis for those with an out-of-range or insufficient newborn screening result was provided to the state public health department according to their guidelines.Newborn ScreeningNormative Statementsno
Req-813Record parental notification of newborn screening diagnosis2013 FormatThe system SHALL record that the child's legal guardians were notified of any newborn screening-related diagnosis.Newborn ScreeningNormative Statementsno
Req-814Provide educational material from health department for newborn screening conditions2013 FormatThe system SHOULD provide parent educational material available from the state public health department regarding the appropriate newborn screening-related condition.Newborn ScreeningNormative Statementsno
Req-815Record diagnoses on patient problem summary list2013 FormatThe system SHOULD include all diagnoses resulting from newborn screening other than 'Normal' on a patient problem summary list.Newborn ScreeningNormative Statementsno
Req-809Report results of non-blood spot newborn screening tests2013 FormatThe system SHALL be able to report results of non-blood spot newborn screening tests to the state public health department according to their guidelines.Newborn ScreeningNormative Statementsno
Req-810Provide ACT sheets to clinicians after out-of-range newborn screening result2013 FormatThe system SHOULD provide guidance to clinicians about the management of an out-of-range newborn screening result by providing the HRSA-funded ACT sheets.Newborn ScreeningNormative Statementsno
Req-811Record final diagnosis for abnormal newborn screening results2013 FormatThe system SHALL record the final diagnosis for those with out-of-range or insufficient newborn screening results. This includes 'Normal' or the particular diagnosis.Newborn ScreeningNormative Statementsno
Req-1103Store codified newborn screening results2013 FormatThe system SHALL be able to store standardized codified newborn screening results to the degree to which they are made available.Newborn ScreeningNormative Statementsno
Req-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-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-2016Record parental notification of newborn screening diagnosis2015 Priority ListThe system shall be able to track that the child's legal guardians were notified of any newborn screening-related diagnosis.Newborn ScreeningNormative Statementyes
Req-2017Record diagnoses on patient problem summary list2015 Priority ListThe system shall be able to record all diagnoses resulting from newborn screening other than 'Normal' and all outstanding newborn screening tasks that have not been performed on a patient problem summary list.Newborn ScreeningNormative Statementyes
Req-2018Support appropriate newborn screening and follow-up2015 Priority ListThe system shall incorporate clinical decision support to assure newborn screening has been accomplished and that results have been followed up.Newborn ScreeningNormative Statementyes
Req-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-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-1233Multiple units of measurement2013 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 Management, Well Child/Preventive CareNormative Statementsno
Req-296Standard Terminologies and Terminology Services2013 Format
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated...
STATEMENT: Support semantic interoperability through the use of standard terminologies, standard terminology models and standard terminology services.

DESCRIPTION: The purpose of supporting terminology standards and services is to enable semantic interoperability. Interoperability is demonstrated by the consistency of human and machine interpretation of shared data and reports. It includes the capture and support of consistent data for templates and decision support logic.

Terminology standards pertain to concepts, representations, synonyms, relationships and computable (machine-readable definitions. Terminology services provide a common way for managing and retrieving these items.
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Medication Management, Special Terminology and InformationHeaderno
Req-715Standard Terminologies and Terminology Models2013 Format
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a...
STATEMENT: Employ standard terminologies to ensure data correctness and to enable semantic interoperability (both within an enterprise and externally
Support a formal standard terminology model.

DESCRIPTION: Semantic interoperability requires standard terminologies combined with a formal standard information model. An example of an information model is the HL7 Reference Information model.
Examples of terminologies that an EHR-S may support include: LOINC, SNOMED, ICD-9, ICD-10, and CPT-4.
A terminology provides semantic and computable identity to its concepts.
Terminologies are use-case dependent and may or may not be realm dependent. For example, terminologies for public health interoperability may differ from those for healthcare quality, administrative reporting, research, etc.
Formal standard terminology models enable common semantic representations by describing relationships that exist between concepts within a terminology or in different terminologies, such as exemplified in the model descriptions contained in the HL7 Common Terminology Services specification.
The clinical use of standard terminologies is greatly enhanced with the ability to perform hierarchical inference searches across coded concepts. Hierarchical Inference enables searches to be conducted across sets of coded concepts stored in an EHR-S.
Relationships between concepts in the terminology are used in the search to recognize child concepts of a common parent. For example, there may be a parent concept, "penicillin containing preparations" which has numerous child concepts, each of which represents a preparation containing a specific form of penicillin (Penicillin V, Penicillin G, etc. Therefore, a search may be conducted to find all patients taking any form of penicillin preparation.
Clinical and other terminologies may be provided through a terminology service internal or external to an EHR-S. An example of a terminology service is described in the HL7 Common Terminology Services specification.
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Medication Management, Special Terminology and InformationFunctionno
Req-1013Standard terminology for medications and treatments2013 Format
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use...
The system SHOULD provide the ability to encode the names of medications and patient treatments commonly used for children using a terminology identified as a standard for documenting medication names.
Comment: EHR systems may use existing terminologies that represent clinical medications, such as MediSpan, First Data Bank or Multum to support this function. However, EHR systems may also maintain their own proprietary medication terminology. In either case, the scope of the functionality for EHR systems relates to their ability to allow users to encode medications according to a standard representation.
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Medication Management, Special Terminology and InformationNormative Statementsno
Req-288Orders and Referrals Management2013 FormatManage Orders and Referrals.Medication Management, Primary Care Management, Well Child/Preventive CareHeaderno
Req-575Non-Medication Orders and Referrals Management2013 FormatManage Non-Medication Orders and ReferralsMedication Management, Primary Care Management, Well Child/Preventive CareHeaderno
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-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-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-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-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-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-703Support for Medication Recommendations2013 Format
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice...
STATEMENT: The system should provide recommendations and options in medication and monitoring on the basis of patient diagnosis, cost, local formularies or therapeutic guidelines and protocols.
DESCRIPTION: Offer alternative medications on the basis of practice standards (e.g. cost or adherence to guidelines a generic brand, a different dosage, a different drug, or no drug (watchful waiting Suggest lab order monitoring as indicated by the medication or the medical condition to be affected by the medication. Support expedited entry of series of medications that are part of a treatment regimen, i.e. renal dialysis, Oncology, transplant medications, etc.
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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-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-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-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-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-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-881Document reasons for drug alert override2013 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-883Future dose calculation 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.
Medication ManagementNormative Statementsno
Req-882Drug dosage computation2013 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-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
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