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You are viewing the Abridged Children's EHR Format.
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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-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-1159Prenatal ultrasound results2013 FormatThe system SHALL capture into the child's chart any specific condition diagnosed by prenatal ultrasound in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1158Preserve codification of maternal data2013 FormatMaternal data, when captured into the child's chart, SHOULD preserve codification when codified in the maternal chart.Prenatal ScreeningNormative Statementsno
Req-1161Prenatal in utero testing results2013 FormatThe system SHALL capture into the child's chart results of any specific condition diagnosed by in utero testing (e.g., amniocentesis in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative Statementsno
Req-1160Prenatal testing results2013 FormatThe system SHALL capture into the child's chart results of maternal testing for conditions in the newborn (e.g., the "quad screen" or "triple screen" in a manner consistent with standard coding (e.g., SNOMED-CTPrenatal ScreeningNormative 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-2026Transferrable access authority2015 Priority ListThe system shall provide a mechanism to enable access control that allows a transferrable access authority, e.g., to address change in guardian, child reaching age of maturity, etc..Patient Portals - PHR, Security and Confidentiality, School-Based LinkagesNormative Statementyes
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-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-1095Transferrable access authority2013 FormatThe system SHALL provide a mechanism to enable access control that allows a transferrable access authority.Patient Portals - PHR, School-Based Linkages, Security and ConfidentialityNormative Statementsno
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-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-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-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-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-1101School-based care delivery data2013 FormatThe system MAY enable controlled access to and display of school based care delivery data.Patient Portals - PHRNormative 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-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-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-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-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-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-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-993Updates to temporary names/demographics2013 FormatThe system SHALL enable updates to demographic information such as replacing the temporary names "Baby 1" to "Baby N" with the actual names, as well as other demographic information, when available.

See Req-992 for demographic information examples.
Patient IdentifierNormative Statementsno
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