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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.

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Req-992Associate mother’s demographics with newborn2013 FormatThe system SHALL provide the ability to associate elements of the mother's demographic information, aside from name and other personal identifiers, with each baby in the single or multiple birth situation.
Example: Street address, telephone number, email address but NOT mother's date of birth, driver's license, etc.
Patient IdentifierNormative Statementsno
Req-990Unique newborn identifiers2013 FormatThe system SHALL generate a unique identifier for each newborn.Patient IdentifierNormative Statementsno
Req-991Temporary newborn names2013 FormatThe system SHALL be able to record temporary names such as "Baby 1" to "Baby N".Patient IdentifierNormative Statementsno
Req-989Birth Demographics2013 FormatIn either single or multiple births the mother's demographics, except for name, are associated with the child. Additionally, the names initially given the baby(ies may be simply "Baby 1," "Baby 2," etc.Patient IdentifierHeaderno
Req-556Document authority for consent on behalf of minors2013 FormatThe system SHALL allow for documentation of authority of foster parents or custodians to give consent on behalf of a minor patient, including unlimited number of different foster parents or custodians.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-557Document time restrictions on authority for consent on behalf of patient2013 FormatThe system SHALL provide the ability to document any time restrictions on the patient's guardian, foster parent or custodian's level of authority to make decisions on behalf of the patient.Parents and Guardians and Family Relationship Data, Security and ConfidentialityNormative Statementsno
Req-1074Capture patient relationships2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsyes
Req-506Capture both presence and absence of conditions in history2013 FormatThe system SHALL provide the ability to capture patient history as both a presence and absence of conditions, i.e., the specification of the absence of a personal or family history of a specific diagnosis, procedure or health risk behavior.Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementsno
Req-248Capture Patient Health Data Derived from Administrative and Financial Data and Documentation2013 Format
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data...
STATEMENT: Capture and explicitly label patient health data derived from administrative or financial data; and link the data source with that data.
DESCRIPTION: It is critically important to be able to distinguish patient health data derived from administrative or financial data from clinically authenticated data. Sources of administrative and financial data relating to a patient's health may provide this data for entry into the health record or be given a mechanism for entering this data directly. The data must be explicitly labeled as derived from administrative or financial data, and information about the source must be linked with that data. Patient health data that is derived from administrative or financial data may be provided by:
1. the patient
2. a provider
3. a payer, or
4. entities that transmit or process administrative or financial data.
Since this data is non-clinical, it may not be authenticated for inclusion in the patient's legal health record. Registration data, which may contain demographic data and pertinent positive and negative histories, is an example of administrative and financial data that may be captured.
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Parents and Guardians and Family Relationship DataFunctionno
Req-489Support interoperability between various systems2013 FormatThe system MAY be interoperable between the juvenile justice system, medical facilities, probation department, schools, and each state's human services agency.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-578Locate records based on previous names2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-584Amend administrative or financial data2013 Format
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You are viewing the Abridged Children's EHR Format. To view the Full Children's EHR Format, you must first agree to the HL7 License Agreement.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-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-683Healthcare Resource Availability2013 Format
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In...
STATEMENT: Support the collection and distribution of local healthcare resource information, through interactions with other systems, applications, and modules, to enable planning and response to extraordinary events such as local or national emergencies.
DESCRIPTION: In times of identified local or national emergencies and upon request from authorized bodies, provide current status of healthcare resources including, but not limited to, available beds, providers, support personnel, ancillary care areas and devices, operating theaters, medical supplies, vaccines, and pharmaceuticals. The intent is to enable the authorized body to distribute or re-distribute either resources or patient load to maximize efficient healthcare delivery. In addition, these functions may also be used for internal assessment and planning purposes by facility administrators
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Parents and Guardians and Family Relationship DataFunctionno
Req-679Identify and Maintain a Patient Record2013 Format
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and...
STATEMENT: Identify and maintain a single patient record for each patient.
DESCRIPTION: A single record is needed for legal purposes, as well as to organize it unambiguously for the provider. Health information is captured and linked to the patient record. Static data elements as well as data elements that will change over time are maintained. The patient is uniquely identified, after which the record is tied to that patient. Combining information on the same patient, or separating information where it was inadvertently captured for the wrong patient, helps maintain health information for a single patient. In the process of creating a patient record, it is at times advantageous to replicate identical information across multiple records, so that such data does not have to be re-entered. For example, when a parent registers children as new patients, the address, guarantor, and insurance data may be propagated in the children's records without having to re-enter them.
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Parents and Guardians and Family Relationship DataFunctionno
Req-702Secure Data Routing2013 Format
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the...
STATEMENT: Route electronically exchanged EHR data only to/from known, registered, and authenticated destinations/sources (according to applicable healthcare-specific rules and relevant standards
DESCRIPTION: An EHR-S needs to ensure that it is exchanging EHR information with the entities (applications, institutions, directories it expects. This function depends on entity authorization and authentication to be available in the system. For example, a physician practice management application in an EHR-S might send claim attachment information to an external entity. To accomplish this, the application must use a secure routing method, which ensures that both the sender and receiving sides are authorized to engage in the information exchange. Known sources and destinations can be established in a static setup or they can be dynamically determined. Examples of a static setup are recordings of IP addresses or recordings of DNS names. For dynamic determination of known sources and destinations systems can use authentication mechanisms as described in Req-759 (HL7 ID: IN.1.1 For example, the sending of a lab order from the EHRS to a lab system within the same organization usually uses a simple static setup for routing. In contrast sending a lab order to a reference lab outside of the organization will involve some kind of authentication process.
In general, when the underlying network infrastructure is secure (e.g. secure LAN or VPN the simple static setup is used.
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Parents and Guardians and Family Relationship DataFunctionno
Req-669Sibling data sharing2013 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-1199Family and patient history of substance abuse2013 FormatThe system SHOULD have access to history of drug or alcohol abuse of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1202Definition of Terms for Parents and Guardians and Family Relationship Data2013 Format
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person...
The following definitions SHOULD be used to manage Parents and Guardians and Family Relationship Data:
Patient's Personal Representative: a minor patient's parent or other person acting in loco parentis, a court-appointed guardian, or a person with durable power of attorney for health care for a patient, the executor or administrator of the patient's estate, or the person responsible for the patient's estate if it is not to be probated.
Guarantor: The guarantor is the person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patients 18 years of age and younger.
Medical Decision Maker: the authority who has the ability to make decisions related to the medical care for a youth. Decision authority may be full or limited, with limited typically allowing consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR. For children in group or residential treatment this is the court or child welfare staff.
Full medical decision making authority: Full authority to make medical decisions (such as consent to treatment and procedures on behalf of the minor. Full medical decision making is typically afforded to parents and in the case of foster children to the state social services agency (via a case worker typically
Limited medical decision making authority: Less than full authority for medical decision making; typically limited decision making (as applies to most foster parent situations allows consent for routine medical care and minor surgical procedures, but not for major surgery or end-of-life decisions such as DNR.
Biological Parent: birthparents or natural parents, the man and woman who conceive a child; also known as genetic parents.
Foster Parent: An adult who takes over care of a minor child who has been placed in the foster care system because the child's own family cannot take care of the child or have had custody taken away by a court or agency. (*Foster parent subcategories and definitions of guardianship may vary from state to state.
Adoptive Parent: A person who completes all the requirements to legally adopt a child who is not his or her biological child.
Surrogate Parent: a woman who agrees to be impregnated by a sperm donor and to carry the child to term, at which time the offspring is surrendered to the care of another.
Custodial Parent: the parent who has physical and/or legal custody of his/her child by court order.
Noncustodial Parent: a parent who does not have physical and/or legal custody of his/her child by court order.
Parental rights: The legal rights and corresponding legal obligations that go along with being the parent of a child.
Legal Guardian: An adult to whom the court has given parental responsibility and authority for a child. Appointment as guardian requires the filing of a petition and approval by the court and can be done without terminating the parental rights of the child's parents. Guardian rights vary by state and sometimes by county. A guardian may or may be the medical consenter. Typically, a guardian may be able to give consent for routine medical care and minor surgical procedures, but not for end-of-life decisions such as DNR (Do Not Resuscitate
Guardian of the Estate: Someone who looks after a child's property.
Guardian of the Person: An adult who has legal authority to make personal decisions for the child, including responsibility for his physical, medical, and educational needs. The medical decision making authority of guardian may be limited.
Full Sibling: is a sibling with whom an individual shares the same biological parents.
Half Sibling (half brother or half sister is a sibling with one shared biological parent.
Agnate Sibling: a half-sibling that shares the same father (but different mothers
Uterine Sibling: a half-sibling that shares the same mother (but different fathers
Case worker: is a person that provides social services and assistance to improve the social and psychological functioning of children and their families and to maximize the family well-being and the academic functioning of children. May assist parents, arrange adoptions, and find foster homes for abandoned or abused children. In schools, they address such problems as teenage pregnancy, misbehavior, and truancy. A job as a Child Welfare Caseworker falls under the broader career category of Child, Family, and School Social Workers. Case workers may work for a governmental or private agency.
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Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1203Navigate between family member charts2013 FormatThe system SHOULD provide a feature to navigate easily between related charts of biological family members (such as mother/baby, parent/child, and siblings without dependence on matching surnames.
Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1200Family and patient history of intimate partner violence2013 FormatThe system SHOULD have access to history of intimate partner violence of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1201Family and patient history of suicidal ideation or depression2013 FormatThe system SHOULD have access to history of suicidal ideation or depression of patient, parents, guardians and siblings in separate sections.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1206Authenticated external access to chart2013 FormatThe system MAY facilitate the ability to search and retrieve certain patient records for an appropriately authenticated external party that requires access to a child's health information.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1204Import/export family member medical data2013 FormatThe system MAY offer a utility to copy or import and export common medical information, such as family history information, from medical records of biological family members.Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1205Import/export family member demographics2013 FormatThe system SHOULD offer a utility to copy or import and export demographic information between records of parents, guardians, and siblings (including foster siblings within the same home.Parents and Guardians and Family Relationship DataNormative Statementsno
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