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Req-98Prompts for safety interventions2013 FormatThe system SHOULD prompt the care provider to recommend specific safety interventions such as warm-up exercises and or equipment based on sport or activity.Activity ClearanceNormative Statementsno
Req-99Nutritional status analysis2013 FormatThe system SHOULD allow for nutritional status analysis during activity clearance examinations.Activity ClearanceNormative Statementsno
Req-96Storage of completed clearance forms2013 FormatThe system SHALL provide for the storage of completed clearance forms for individual patients from various agencies, e.g., School District or youth organizations.Activity ClearanceNormative Statementsno
Req-97Sport/Activity-specific exams2013 Format
The system SHALL allow for sport- or activity-specific examinations as outlined by groups such as the American Heart Association (AHA American Academy of Pediatrics (AAP and American Medical Association (AMA For example, supporting the inclusion...
The system SHALL allow for sport- or activity-specific examinations as outlined by groups such as the American Heart Association (AHA American Academy of Pediatrics (AAP and American Medical Association (AMA For example, supporting the inclusion of an EKG for participants in contact sports such as football. These data SHOULD be stored as distinct data elements.
AAP Preparticipation Physical Evaluation: http://www.aap.org/sections/sportsmedicine/PPEAbout.cfm Exit Disclaimer
AHA Recommendations for Physical Activity and Recreational Sports Participation for Young Patients With Genetic Cardiovascular Diseases: http://circ.ahajournals.org/content/109/22/2807.full#sec-10 Exit Disclaimer
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Activity ClearanceNormative Statementsno
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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Req-284Measurement, Analysis, Research and Reports2013 FormatSystem supports measurement, analysis, research and reports.
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures,...
Activity Clearance, Birth Information, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Patient Identifier, Primary Care Management, Quality Measures, Registry Linkages, Security and Confidentiality, Well Child/Preventive Care
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Req-250Report Generation2013 Format
STATEMENT: Support the export of data or access to data necessary for report generation and ad hoc analysis.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for the generation of both standard...
STATEMENT: Support the export of data or access to data necessary for report generation and ad hoc analysis.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for the generation of both standard and ad hoc reports. These reports may be needed for clinical, administrative, and financial decision-making, as well as for patient use. Reports may be based on structured data and/or unstructured text from the patient's health record.
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Activity Clearance, Birth Information, EPSDT, Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, Well Child/Preventive CareHeaderno
Req-278Standard Report Generation2013 Format
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making,...
STATEMENT: Provide report generation features using tools internal or external to the system, for the generation of standard reports.
DESCRIPTION: Providers and administrators need access to data in the EHR-S for clinical, administrative, financial decision-making, audit trail and metadata reporting, as well as to create reports for patients. Many systems may use internal or external reporting tools to accomplish this (such as Crystal Report
Reports may be based on structured data and/or unstructured text from the patient's health record.
Users need to be able to sort and/or filter reports. For example, the user may wish to view only the diabetic patients on a report listing patients and diagnoses.
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Activity Clearance, Birth Information, EPSDT, Well Child/Preventive CareFunctionno
Req-286Summary Lists2013 FormatSystems ability to capture summary lists.
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family...
Activity Clearance, Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Req-280Clinical Decision Support2013 FormatSystem supports Clinical Decision Support.
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Patient Portals - PHR, Primary Care Management, Registry Linkages, Well Child/Preventive Care
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Req-281Documentation of Care, Measurements and Results2013 FormatSystem will document Care, Measurements and Results
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages,...
Activity Clearance, Children with Special Healthcare Needs, EPSDT, Growth Data, Immunizations, Medication Management, Newborn Screening, Primary Care Management, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive Care
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Req-257Manage Immunization Administration2013 Format
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance...
STATEMENT: Capture and maintain discrete data concerning immunizations given to a patient including date administered, type, manufacturer, lot number, and any allergic or adverse reactions. Facilitate the interaction with an immunization registry to allow maintenance of a patient's immunization history.
DESCRIPTION: During an encounter, recommendations based on accepted immunization schedules are presented to the provider. Allergen and adverse reaction histories are checked prior to giving the immunization. If an immunization is administered, discrete data elements associated with the immunization including date, type, manufacturer and lot number are recorded. Any new adverse or allergic reactions are noted. If required, a report is made to the public health immunization registry.
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Activity Clearance, EPSDT, Immunizations, Registry LinkagesFunctionno
Req-108Support for Health Maintenance: Preventive Care and Wellness2013 FormatSystem supports Preventive Care and Wellness aspects of health maintenance.Activity Clearance, EPSDT, Newborn Screening, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareHeaderno
Req-610Reporting immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsyes
Req-600Report immunization history2013 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.
Activity Clearance, ImmunizationsNormative Statementsno
Req-258Manage Immunization List2013 Format
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured...
STATEMENT: Create and maintain patient-specific immunization lists.
DESCRIPTION: Immunization lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. Details of immunizations administered are captured as discrete data elements including date, type, manufacturer and lot number. The entire immunization history is viewable.
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Activity Clearance, Immunizations, Medication ManagementFunctionno
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-676Generate structured clinical and administrative 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.
Activity Clearance, Well Child/Preventive CareNormative Statementsno
Req-1088Prompts to discuss additional health matters2013 FormatThe system MAY prompt the care provider to discuss additional health matters potentially related to the anticipated activity for which clearance is sought.Activity Clearance, Well Child/Preventive CareNormative Statementsno
Req-93Birth date format2013 FormatThe system SHALL record Birth Date (MM:DD:YYYYBirth InformationNormative Statementsno
Req-95Link maternal and birth data to child health record2013 FormatThe system SHALL provide for the linking or recording of maternal and birth data to the child health record. Examples: maternal social history, maternal prenatal results, and gravida/para (GPBirth InformationNormative Statementsno
Req-125Capture Data and Documentation from External Clinical Sources2013 FormatIncorporate clinical data and documentation from external sources. Mechanisms for incorporating external clinical data and documentation (including identification of source such as image documents and other clinically relevant data are available. Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate.Birth InformationFunctionno
Req-838Precise birth date and time storage2013 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.
Birth InformationNormative Statementsno
Req-837Precise birth date and time entry2013 FormatThe system SHALL enable entry of the date and time of birth (no less precisely than to the minute if required by the scope of practice.Birth InformationNormative Statementsyes
Req-956Blood use in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of blood products used during resuscitation.Birth InformationNormative Statementsno
Req-957Record delivery room procedures2013 FormatThe system SHALL record any procedures performed in the delivery room including intubation, thoracocentesis, line placement, etc., and their timing.Birth InformationNormative Statementsno
Req-958Surfactant administration in delivery room2013 FormatThe system SHALL record any surfactant administration in the delivery room.Birth InformationNormative Statementsno
Req-952Epinephrine in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of epinephrine used during resuscitation.Birth InformationNormative Statementsno
Req-953Normal saline in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of normal saline solution used during resuscitation.Birth InformationNormative Statementsno
Req-954Calcium chloride in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of calcium chloride used during resuscitation.Birth InformationNormative Statementsno
Req-955Na-bicarbonate in neonatal resuscitation2013 FormatThe system SHALL record the dose, route, and frequency of sodium bicarbonate used during resuscitation.Birth InformationNormative Statementsno
Req-948Neonatal Resuscitation2013 FormatResuscitation is common in the delivery room and the steps taken must be documented as part of the record.Birth InformationFunctionno
Req-949Respiratory support in neonatal resuscitation2013 FormatThe system SHALL record respiratory support used during resuscitation (Blow-by O2, Nasal Cannula O2, Bag / Mask Ventilation, CPAP, or Endotracheal IntubationBirth InformationNormative Statementsno
Req-950FiO2 administration in neonatal resuscitation2013 FormatThe system SHALL record the FiO2 delivered to the infant during resuscitation.Birth InformationNormative Statementsno
Req-951Chest compression duration in neonatal resuscitation2013 FormatThe system SHALL record the duration of chest compressions if used during resuscitation.Birth InformationNormative Statementsno
Req-944Oxygen saturation in delivery room2013 FormatThe system SHALL record percutaneous oxygen saturation measurements in the delivery room.Birth InformationNormative Statementsno
Req-945Clinical staff at delivery2013 FormatThe system SHALL record the pediatrician(s nurse(s and respiratory therapist(s present at delivery.Birth InformationNormative Statementsno
Req-947Neonatal physical exam2013 FormatThe system SHALL record the physical exam of the neonate.Birth InformationNormative Statementsno
Req-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.Birth InformationNormative Statementsno
Req-937Record delivery assistance2013 FormatThe system SHALL record if any delivery assistance was required (No Assistance, Forceps, Mid Forceps, High Forceps, or Vacuum ExtractionBirth InformationNormative Statementsno
Req-936Record mechanism of delivery2013 FormatThe system SHALL record the mechanism of delivery (Spontaneous Vaginal Delivery or SVD, Assisted Vaginal Delivery, Precipitous Vaginal Delivery, Emergent Cesarean section, Elective Cesarean sectionBirth InformationNormative Statementsno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth InformationNormative Statementsno
Req-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-935Record color of amniotic fluid2013 FormatThe system SHALL record the color of amniotic fluid (clear, cloudy, bloody, light meconium, moderate meconium, thick meconium, terminal meconiumBirth InformationNormative Statementsno
Req-934Rupture of membranes details2013 FormatThe system SHALL record if rupture of membranes was spontaneous (SROM artificial (AROM premature (PROM or preterm, premature (PPROMBirth InformationNormative Statementsno
Req-929Record tocolytics administration2013 FormatThe system SHALL record whether mother received tocolytics and, if so, which one(sBirth InformationNormative Statementsno
Req-928Perinatal magnesium sulfate administration2013 FormatThe system SHALL record whether the mother received magnesium sulfate doses prior to or during delivery.Birth InformationNormative Statementsno
Req-931Additional medications during pregnancy2013 FormatThe system SHALL record any additional prescription and non-prescription medications and supplements (with name, dose, frequency, and route that the mother took during pregnancy.Birth InformationNormative Statementsno
Req-930Perinatal antibiotic administration2013 FormatThe system SHALL record the type, date, time, and number of antibiotic doses administered before and during delivery.Birth InformationNormative Statementsno
Req-926Medication use during pregnancy2013 FormatPrescribed medications taken during pregnancy or near the time of birth are important for the care of a newborn infant.Birth InformationFunctionno
Req-927Betamethasone prior to delivery2013 FormatThe system SHOULD record the date and time of all Betamethasone doses given to the mother prior to delivery.Birth InformationNormative Statementsno
Req-924Illicit drug use during pregnancy2013 FormatThe system SHALL record other illicit drugs used during pregnancy (Positive, Negative, or Unknown IF positive THEN the system SHALL record the name, dose and frequency of use.Birth InformationNormative Statementsno
Req-925Maternal drug screening results2013 FormatThe system SHALL record drug screening results including drug tested and results (Positive, Negative, or UnknownBirth InformationNormative Statementsno
Req-922Narcotics use during pregnancy2013 FormatThe system SHALL record narcotics use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of narcotics used per day.Birth InformationNormative Statementsno
Req-923Amphetamine use during pregnancy2013 FormatThe system SHALL record amphetamine use during pregnancy as Positive, Negative, or Unknown, as well as the type and average amount of amphetamine used per day.Birth InformationNormative Statementsno
Req-920THC use during pregnancy2013 FormatThe system SHALL record THC use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of THC used per day.Birth InformationNormative Statementsno
Req-921Cocaine use during pregnancy2013 FormatThe system SHALL record cocaine use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of cocaine used per day.Birth InformationNormative Statementsno
Req-918Alcohol use during pregnancy2013 FormatThe system SHALL record alcohol use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of alcohol used per day.Birth InformationNormative Statementsno
Req-919Tobacco use during pregnancy2013 FormatThe system SHALL record tobacco use during pregnancy as Positive, Negative, or Unknown, as well as the average amount of tobacco used per day.Birth InformationNormative Statementsno
Req-916Prenatal care provider information2013 FormatThe system SHALL record the prenatal care provider's name and practice affiliation.Birth InformationNormative Statementsno
Req-917Maternal substance abuse and social history2013 FormatMaternal social history and history of substance abuse can have a dramatic impact on the care of a newborn infant.Birth InformationFunctionno
Req-914Maternal gonorrhea status2013 FormatThe system SHALL record maternal gonorrhea status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-915Maternal chlamydia status2013 FormatThe system SHALL record maternal chlamydia Status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-912Maternal HIV status2013 FormatThe system SHALL record maternal HIV status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
Req-911Maternal VDRL status2013 FormatThe system SHALL record maternal syphilis status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-910Maternal hepatitis B status2013 FormatThe system SHALL record maternal hepatitis B status as Positive, Negative, Unknown or Pending.Birth InformationNormative Statementsno
Req-909Maternal sickle cell status2013 FormatThe system SHALL record maternal sickle cell status as HbSS, HbSC, HbS-Thal, Negative or Unknown.Birth InformationNormative Statementsno
Req-908Maternal rubella status2013 FormatThe system SHALL record maternal rubella status as Immune, Non-Immune or Unknown.Birth InformationNormative Statementsno
Req-907Maternal antibody status2013 FormatThe system SHALL record maternal antibody status.Birth InformationNormative Statementsno
Req-906Maternal blood type2013 FormatThe system SHALL record maternal blood type.Birth InformationNormative Statementsno
Req-905Maternal GPAL2013 FormatThe system SHALL record maternal Gravida / Para / Abortus status / Living Children (GPALBirth InformationNormative Statementsno
Req-904Maternal Data and Labs2013 FormatMaternal laboratory data and serologies are critical to the care of a newborn infant.Birth InformationFunctionno
Req-903Symmetry2013 FormatThe system SHALL record symmetry at birth as Symmetrical or Asymmetrical.Birth InformationNormative Statementsno
Req-902Infant size relative to gestational age2013 FormatThe system SHALL provide the ability to capture, record and store the birth weight, length and head circumference of the infant relative to normal values for its captured and/or assigned gestational age (SGA=Small for Gestational Age, AGA=Appropriate for Gestational Age, LGA=Large for Gestational AgeBirth InformationNormative Statementsno
Req-900Record singleton, twin, or multiple gestation2013 FormatThe system SHALL record whether the infant is a singleton, twin, or multiple gestation.Birth InformationNormative Statementsno
Req-899Gestational age based on Dubowitz or Ballard2013 FormatThe system SHALL record gestational age in weeks based on Dubowitz scoring or Ballard Exam.Birth InformationNormative Statementsno
Req-898Gestational age in weeks and days2013 FormatThe system SHALL record gestational age in weeks and days based on last menstrual period (LMP ultrasound, or maternal report.Birth InformationNormative Statementsyes
Req-897Birth weight in kg2013 FormatThe system SHALL record birth weight in kilograms to 3 decimal places.Birth InformationNormative Statementsno
Req-1197Auto-populate birth certificate2013 FormatThe system SHOULD be able to auto-populate a birth certificate.Birth InformationNormative Statementsno
Req-2001Link maternal and birth data to child health record2015 Priority ListThe system shall import birth information from an electronic newborn discharge summary as discrete data elements.
All other requirements, such as gestation age, can be incorporated into a birth data elements list.
Birth InformationNormative Statementyes
Req-268Manage Patient History2013 Format
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient...
STATEMENT: Capture and maintain medical, procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.
DESCRIPTION: The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band or electronic or non-electronic historical data. This data may take the form of a pertinent positive such as: "The patient/family member has had..." or a pertinent negative such as "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate.
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Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening,...
Birth Information, Child Abuse Reporting, Child Welfare, Genetic information, Parents and Guardians and Family Relationship Data, Patient Identifier, Prenatal Screening, Primary Care Management, Security and Confidentiality, Specialized Scales/Scoring, Well Child/Preventive Care
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Functionno
Req-579Report demographic 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.
Birth Information, 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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Req-128Manage Patient Demographics2013 Format
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth,...
STATEMENT: Capture and maintain demographic information. Where appropriate, the data should be clinically relevant and reportable.
DESCRIPTION: Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, time of birth, gestation, gender, and other information is stored and maintained for unique patient identification, reporting purposes and for the provision of care. Patient demographics are captured and maintained as discrete fields (e.g., patient names and addresses and may be enumerated, numeric or codified. Key patient identifiers are shown on all patient information output (such as name and ID# on each screen of a patient's record The system will track who updates demographic information, and when the demographic information is updated.
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Birth Information, Child Welfare, Genetic information, Growth Data, Patient Identifier, Prenatal Screening, Well Child/Preventive CareFunctionno
Req-297Clinical Support2013 FormatSystem provides Clinical Support.
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well...
Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive Care
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Headerno
Req-277Registry Notification2013 Format
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal...
STATEMENT: Enable the automated transfer of formatted demographic and clinical information to and from local disease specific registries (and other notifiable registries for patient monitoring and subsequent epidemiological analysis.
DESCRIPTION: The user can export personal health information to disease specific registries, other notifiable registries such as immunization registries, through standard data transfer protocols or messages. The user can update and configure communication for new registries.
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Birth Information, Children with Special Healthcare Needs, Genetic information, Immunizations, Registry LinkagesFunctionno
Req-1007Copy and paste selected information from another medical record/chart2013 Format
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL...
The System SHALL support copying of selected information from another chart to the child's chart. Examples include copying from either biologic parent for genetic information, or the maternal chart for prenatal information. This copying SHALL support suppression of the maternal identity in cases that require parental confidentiality (e.g. voluntary surrender for adoption, or removal from the mother's care for other reasons
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Birth Information, Genetic information, Patient Identifier, Prenatal Screening, Security and ConfidentialityNormative Statementsno
Req-582Indicate unknown patient gender2013 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.
Birth Information, Genetic information, Prenatal ScreeningNormative Statementsno
Req-583Compute post conceptional age2013 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.
Birth Information, Growth Data, Prenatal ScreeningNormative Statementsno
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-94Birth order: familial rank2013 FormatThe system SHOULD have the ability to record Birth Order (Familial RankBirth Information, Patient IdentifierNormative 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-896Growth and Developmental Parameters2013 FormatIntrauterine growth, symmetry, and maturation are critical aspects of the birth history.Birth Information, Patient IdentifierFunctionno
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-1198Birth information to state vital statistics registry2013 FormatThe system SHOULD provide birth information to the appropriate state vital statistics registry.Birth Information, Registry LinkagesNormative Statementsno
Req-94110 minute Apgar2013 FormatThe system SHALL record Apgar score at 10 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-9405 minute Apgar2013 FormatThe system SHALL record Apgar score at 5 minutes (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-942Continuing Apgar scores2013 FormatThe system MAY record Apgar score at every 5 minutes after 10 minutes if the total score is less than; 5 (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative Statementsno
Req-9391 minute Apgar2013 FormatThe system SHALL record Apgar score at 1 minute (HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10Birth Information, Specialized Scales/ScoringNormative 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-517Ability to access family history, including all parents2013 FormatThe system SHALL provide the ability to access family history, including all parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers; with contact information for each.Child Abuse ReportingNormative Statementsno
Req-518Ability to retrieve, capture, store, and display information regarding forensic evaluations2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display information regarding forensic evaluations.Child Abuse ReportingNormative Statementsno
Req-519Ability to access, store, and retrieve the date, time, and place of the occurrence2013 FormatThe system SHALL provide the ability to access, store, and retrieve the date, time, and place of the occurrence of alleged abuse.Child Abuse ReportingNormative Statementsno
Req-512Support communication with national, state, and local Child Protective Services, and more2013 FormatThe system MAY communicate with national, state, and local Child Protective Services, law enforcement, care physicians, prosecutor, medical examiner, Medicaid, and Insurance companies.Child Abuse ReportingNormative Statementsno
Req-520Ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings2013 FormatThe system SHALL provide the ability to access, store, and retrieve a detailed description of the genital examination, photographs or drawings of findings (both sexual and physical documentation of laboratory studies, and radiographic studies.Child Abuse ReportingNormative Statementsno
Req-522Ability to retrieve, capture, store, and display service plans, progress summaries, and assessments2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display service plans, progress summaries, and assessments.Child Abuse ReportingNormative Statementsno
Req-1175Past history of abuse and neglect for the child2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect for the child.Child Abuse ReportingNormative Statementsno
Req-1176Past history of abuse and neglect by perpetrator2013 FormatThe system SHOULD provide the ability to retrieve, capture, store, and display a past history of substantiated instances of abuse and neglect by the alleged perpetrator.Child Abuse ReportingNormative Statementsno
Req-1177Maintain unsubstantiated instances of abuse or neglect2013 Format
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability...
The system SHOULD provide the ability to maintain indicated unsubstantiated instances of abuse or neglect consistent with the prevailing law (which may be state, federal, tribal or local depending on situational factors with the ability to expunge or limit communication to certain external systems unsubstantiated instances of abuse or neglect when required by the prevailing law.
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Child Abuse ReportingNormative Statementsno
Req-1178Manage roles and permissions for child abuse data2013 FormatThe system SHOULD provide the ability to define and manage roles and permissions to access specific sections of the system with role-based access including, but not limited to, access to child abuse data by child welfare agents and physicians.Child Abuse ReportingNormative Statementsno
Req-1179History of termination of parental rights from within EHR2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display a past history of termination of parental rights documented within the native EHR system for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1180History of termination of parental rights from an external information source2013 FormatThe system MAY provide the ability to retrieve, capture, store, and display a past history of termination of parental rights from an external information source (e.g. registry for the parents of the child involved in child welfare.Child Abuse ReportingNormative Statementsno
Req-1181Notification to child welfare per mandate2013 Format
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as...
The system MAY provide an option to notify child welfare when a suspected case of child abuse includes a past history of termination of parental rights, to support the mandate in several jurisdictions (such as state, tribal or other authority that child welfare be notified in instances of abuse that includes a past history of termination of parental rights.
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Child Abuse ReportingNormative Statementsno
Req-1187Suspected abuse and neglect information from standardized questions2013 FormatThe system SHOULD provide the ability to capture suspected abuse and neglect information via standardized intake questions with answers being provided on a standard scale to indicate the alleged abuse.Child Abuse ReportingNormative Statementsno
Req-1186Capture child abuse details2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history...
The system SHOULD provide the ability to retrieve, capture, store, and display the details of the child abuse-related assault for both the child and the adult (and in cases of physical abuse, a developmental history specific sexual acts; and mechanism of injury in separate sections (e.g. one section for alleged perpetrator and one section for child
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Child Abuse ReportingNormative Statementsno
Req-1184Data related to outcome measures for welfare agencies2013 FormatThe system SHOULD provide the ability to include data elements that are related to federally required outcome measures as may be requested by child welfare agencies.Child Abuse ReportingNormative Statementsno
Req-1190Disposition of abuse allegations from external source2013 Format
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for...
The system MAY provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect from an external information source (e.g. registry and SHOULD use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
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Child Abuse ReportingNormative Statementsno
Req-1189Disposition of abuse allegations within the EHR2013 Format
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions...
The system SHALL provide the ability to retrieve, capture, store, and display disposition of all allegations of abuse and/or neglect within the native EHR system, and SHALL use the standard federal categorization for these dispositions (Substantiated, Indicated, or Unfounded along with the ability to utilize custom subcategories which can vary from jurisdiction to jurisdiction.
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Child Abuse ReportingNormative Statementsno
Req-1188Standardized CDC categorization for child abuse2013 FormatThe system SHOULD use the standardized CDC categorization for child abuse and neglect with the ability for states to utilize specific categorization both in the past history and current assessment. The Center for Disease Control and Prevention details further guidance on data definitions for child abuse and neglect.Child Abuse ReportingNormative Statementsno
Req-1195Externally documented abuse by caregivers2013 Format
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed...
The system MAY provide the ability to retrieve, capture, store, and display a history of abuse or neglect (from an external information source, e.g. registry by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
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Child Abuse ReportingNormative Statementsno
Req-1194EHR-documented abuse by caregivers2013 Format
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day...
The system SHOULD provide the ability to retrieve, capture, store, and display a history of abuse or neglect (documented within the native EHR system by family members, and other providers, such as babysitters, licensed day care providers, teachers, and others that are in contact with child at time of alleged abuse.
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Child Abuse ReportingNormative Statementsno
Req-254Manage Assessments2013 Format
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the...
STATEMENT: Create and maintain assessments.
DESCRIPTION: During an encounter with a patient, the provider will conduct an assessment that is germane to the age, gender, developmental or functional state, medical and behavioral condition of the patient, such as growth charts, developmental profiles, and disease specific assessments. Wherever possible, this assessment should follow industry standard protocols although, for example, an assessment for an infant will have different content than one for an elderly patient. When a specific standard assessment does not exist, a unique assessment can be created, using the format and data elements of similar standard assessments whenever possible.
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Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care...
Child Abuse Reporting, Child Welfare, Children with Special Healthcare Needs, EPSDT, Parents and Guardians and Family Relationship Data, Primary Care Management, Registry Linkages, Special Terminology and Information, Well Child/Preventive Care
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Functionno
Req-1214Child Abuse Reporting and Welfare2013 FormatChild Abuse Reporting, Child Welfare, Primary Care Management, Registry Linkages, Well Child/Preventive CareFunctionno
Req-1193Link to Child Welfare registries2013 FormatThe system SHOULD provide an interface or link to child welfare registries to be searchable by name (either child or parent placement, service categories provided, and/or jurisdiction.Child Abuse Reporting, Child Welfare, Registry LinkagesNormative Statementsno
Req-1278History of Abuse and Neglect2013 FormatHistory of Abuse and NeglectChild Abuse Reporting, Child Welfare, Well Child/Preventive CareFunctionno
Req-1185Well-being measures relevant to child welfare2013 Format
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known...
The system SHOULD capture well-being measures relevant to child welfare agents. Well-being measures are defined as: (1 Health: date and reason for health screenings, ED visits, hospitalizations; presence of a primary physician, presence of known diseases, etc., (2 Education: school name and date (the child can be transient presence of an IEP or 504 plan, (3 School performance: above, at, or below grade level; number of absences (excused or unexcused graduation date or presence of a GED, etc., (4 Employment and/or Higher Education: employment status; taking post-HS courses or not.
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Child Abuse Reporting, Child Welfare, Well Child/Preventive CareNormative Statementsno
Req-1191Mental health, learning, and developmental history2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's developmental stage, learning barriers, mental health history, and current therapy related to development, learning, or mental health/substance abuse (e.g., speech therapy, cognitive therapy, and antidepressantsChild Abuse Reporting, EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1182Store and retrieve restraining and visitation order information2013 FormatThe system SHALL provide the ability to access, store, and retrieve any restraining orders, visitation orders and the person or organization with decision making authority within the native EHR system.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1183Access restraining and visitation order information from external source2013 FormatThe system MAY provide the ability to access, store, and retrieve from an external information source (e.g. registry any restraining or visitation orders, and the person or organization with decision making authority.Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-1192Family history relationships2013 Format
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents...
The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.The system SHALL provide the ability to retrieve, capture, store and display family history including the patient's personal representatives (for example: parent, guardian, surrogate, financial guarantor and personal relationships including all current and past parents (biological, foster, adoptive, guardian, surrogate, and custody siblings, and case workers, with name and contact information for each to include one or more telephone numbers, email addresses, and physical addresses.
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Child Abuse Reporting, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-2006Ability to access family history, including all guardians and caregivers2015 Priority ListThe system shall provide the ability to record information about all guardians and caregivers (biological parents, foster parents, adoptive parents, guardians, surrogates, and custodians siblings, and case workers; with contact information for each.Child Abuse Reporting, Parents and Guardians and Family Relationship Data, Primary Care ManagementNormative Statementyes
Req-515Ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance2013 FormatThe system SHALL provide the ability to retrieve, capture, store, and display information regarding the child's response, demeanor, and appearance.Child Abuse Reporting, Primary Care Management, Well Child/Preventive CareNormative 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-580Historical demographic 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.
Child WelfareNormative Statementsno
Req-1221Placement setting in out-of-home care2013 FormatThe system SHALL have the ability to store, retrieve and display the current placement setting of the child in out-of-home care.Child WelfareNormative Statementsno
Req-1220Clinical issues displayed to non-clinicians2013 FormatThe system SHOULD have the ability to display known interaction effects, known concerns and side-effects, or contraindications to authorized viewers of data external to clinicians, such as child welfare case workers.Child WelfareNormative Statementsno
Req-1223Out-of-home care history2013 FormatThe system SHALL have the ability to store, retrieve, and display whether the child has ever been in out-of-home care (yes or no is sufficientChild WelfareNormative Statementsno
Req-1217Adoption history2013 Format
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information...
The system SHALL have the ability to store, retrieve, and display the child's adoption history (whether adopted, expressed as yes or no, is sufficient

Example: If the child is adopted then family history information captured might not be clinically relevant. Further, the decision support relying on family history may be irrelevant and therefore the EHR system should exclude family history of adoptee in decision support logic.
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Child WelfareNormative Statementsno
Req-1216Type of placement2013 FormatThe system SHALL have the ability to store, retrieve, and display the type of placement (e.g., voluntary placement, court ordered placementChild WelfareNormative Statementsno
Req-1229State agencies providing services2013 FormatThe system SHOULD have access to whether the child is being served by any other state agency and list each agency, when available.Child WelfareNormative Statementsno
Req-1231Alert for foster care without Medicaid2013 FormatThe system SHALL have the ability to provide an option to alert where a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementsno
Req-1230Medicaid case number2013 FormatThe system SHALL have the ability to store, retrieve, and display information about the child's Medicaid case number.Child WelfareNormative Statementsno
Req-1225Welfare court proceedings and legal status2013 FormatThe system SHOULD store, retrieve, and display the stage of court proceedings and legal status (e.g., court ordered placement in out of home care, detained, pre-adjudication versus sentenced, post-adjudication when available.Child WelfareNormative 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-1227Legal history2013 FormatThe system SHOULD have access to the legal history (e.g., first-time offender versus repeat offender, multiple incarcerations when available.Child WelfareNormative Statementsno
Req-1226Identification of additional births for parents with prior Termination of Parental Rights2013 FormatThe system MAY have the ability to connect with vital records to identify additional births to parents who have had a prior Termination of Parental Rights, when available.Child WelfareNormative Statementsno
Req-1215Family, psychosocial, and child welfare resources2013 FormatThe system SHOULD have the ability to store, retrieve, and display a list of family, psychosocial, and child welfare resources.Child WelfareNormative Statementsno
Req-2031Adoption history2015 Priority ListThe system shall have the ability to record a child's adoption history.Child WelfareNormative Statementyes
Req-2033Placement setting in out-of-home care2015 Priority ListThe system shall have the ability to record a child’s history of and/or current placement in foster care, with relevant date(s in care.Child WelfareNormative Statementyes
Req-2034Alert for foster care without Medicaid2015 Priority ListThe system shall have the ability to provide an option to alert when a child in foster care is not enrolled in Medicaid.Child WelfareNormative Statementyes
Req-694Registry and Directory Services2013 Format
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and...
STATEMENT: Enable the use of registry services and directories to uniquely identify, locate and supply links for retrieval of information related to:
- patients and providers for healthcare purposes;
- payers, health plans, sponsors, and employers for administrative and financial purposes;
- public health agencies for healthcare purposes, and
- healthcare resources and devices for resource management purposes.
DESCRIPTION: Registry and directory service functions are critical to successfully managing the security, interoperability, and the consistency of the health record data across an EHR-S. These services enable the linking of relevant information across multiple information sources within, or external to, an EHR-S for use within an application.
Directories and registries support communication between EHR Systems and may be organized hierarchically or in a federated fashion. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider's EHR-S interrogates a local, regional, or national registry to find the patient's previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules.
An example of local registry usage is an EHR-S application sending a query message to the Hospital Information System to retrieve a patient's demographic data.
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Child Welfare, Children with Special Healthcare Needs, Growth Data, Immunizations, Registry Linkages, Well Child/Preventive CareFunctionno
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-282Operations Management and Communication2013 FormatSystem supports Operations Management and Communication.Child Welfare, Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-263Manage Problem List2013 Format
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists...
STATEMENT: Create and maintain patient- specific problem lists.
DESCRIPTION: A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient, allowing documentation of historical information and tracking the changing character of problem(s and their priority. The source (e.g. the provider, the system id, or the patient of the updates should be documented. In addition all pertinent dates are stored. All pertinent dates are stored, including date noted or diagnosed, dates of any changes in problem specification or prioritization, and date of resolution. This might include time stamps, where useful and appropriate. The entire problem history for any problem in the list is viewable.
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Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareFunctionno
Req-1210Pediatric conditions and supporting technology2013 FormatThe system SHALL provide the ability to access, capture, store, and display a child's active or chronic conditions and illnesses, mental illness, and technology support needs (ventilator, monitor, surgical site care, wound vac, etc.Child Welfare, Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-253Manage Allergy, Intolerance and Adverse Reaction List2013 Format
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates,...
STATEMENT: Create and maintain patient-specific allergy, intolerance and adverse reaction lists.
DESCRIPTION: Allergens, including immunizations, and substances are identified and coded (whenever possible and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s includes all reactions including those that are classifiable as a true allergy, intolerance, side effect or other adverse reaction to drug, dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are maintained.
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Child Welfare, Immunizations, Medication Management, Parents and Guardians and Family Relationship Data, Registry Linkages, Well Child/Preventive CareFunctionno
Req-1222Rights to authorize care and release information2013 FormatThe system SHALL have the ability to store, retrieve, and display information about rights to authorize care and to release information, as well as relevant consent forms.Child Welfare, Parents and Guardians and Family Relationship DataNormative Statementsno
Req-294Security2013 Format
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce...
STATEMENT: Secure the access to an EHR-S and EHR information. Manage the sets of access control permissions granted within an EHR-S. Prevent unauthorized use of data, data loss, tampering and destruction.

DESCRIPTION: To enforce security, all EHR-S applications must adhere to the rules established to control access and protect the privacy of EHR information. Security measures assist in preventing unauthorized use of data and protect against loss, tampering and destruction. An EHR-S must be capable of including or interfacing with standards-conformant security services to ensure that any Principal (user, organization, device, application, component, or object accessing the system or its data is appropriately authenticated, authorized and audited in conformance with local and/or jurisdictional policies.

An EHR-S should support Chains of Trust in respect of authentication, authorization, and privilege management, either intrinsically or by interfacing with relevant external services.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security...
Child Welfare, Parents and Guardians and Family Relationship Data, Patient Identifier, Patient Portals - PHR, Prenatal Screening, School-Based Linkages, Security and Confidentiality
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Headerno
Req-718Entity Access Control2013 Format
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of...
STATEMENT: Verify and enforce access control to all EHR-S components, EHR information and functions for end-users, applications, sites, etc., to prevent unauthorized use of a resource.
DESCRIPTION: Entity Access Control is a fundamental function of an EHR-S. To ensure that access is controlled, an EHR-S must perform authentication and authorization of users or applications for any operation that requires it and enforce the system and information access rules that have been defined.
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Child Welfare, Parents and Guardians and Family Relationship Data, Patient Portals - PHR, Security and ConfidentialityFunctionno
Req-1207Manage progress summaries, assessments, and service plans2013 FormatThe system SHOULD retrieve, capture, store, and display a child's progress summaries, assessments, and service plans.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1211Manage child’s health history2013 FormatThe system SHALL provide the ability to access, capture, store, display, and manage a child's health history including medication lists, medication allergies, adverse reactions, and immunizations.Child Welfare, Parents and Guardians and Family Relationship Data, Well Child/Preventive CareNormative Statementsno
Req-1219Authorized user details2013 FormatThe system SHALL have the ability to capture and display the name, contact information, and relationship/role of each authorized viewer of EHR data.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-1218Authorized non-clinician viewers of EHR data2013 FormatThe system SHOULD have the ability to display clinical information to authorized non-clinician viewers of EHR data, such as child welfare case workers and other authorized members of the child's care team.Child Welfare, Patient Portals - PHRNormative Statementsno
Req-2032Authorized non-clinician viewers of EHR data2015 Priority ListThe system shall have the ability to identify members of the care team (including professional and nonprofessional members and indicate their roles/relationships to the child.Child Welfare, Patient Portals - PHRNormative Statementyes
Req-484Document communication with providers or agencies2013 FormatThe system SHALL provide the ability to document in the patient record verbal/telephone communication with providers or agencies whether internal or external to the organization.Child Welfare, Primary Care ManagementNormative Statementsno
Req-570Support for Inter-Provider Communication2013 Format
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or...
STATEMENT: Support exchange of information between providers as part of the patient care process, and the appropriate documentation of such exchanges. Support secure communication to protect the privacy of information as required by federal or jurisdictional law.
DESCRIPTION: Communication among providers involved in the care process can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room to asynchronous communication (for example, consult reports between physicians Some forms of inter-practitioner communication will be paper based and the EHR-S must be able to produce appropriate documents.
The system should provide for both verbal and written communication. These exchanges would include but not limited to consults, and referrals as well as possible exchanges within the office as part of the provision and administration of patient care (for example, the communication of new information obtained within the office environment during the process of administration of a tetanus shot while the patient is in the exam room
The system should support the creation and acceptance of paper artifacts where appropriate.
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Child Welfare, Primary Care ManagementFunctionno
Req-472Communicate with local service registries2013 FormatThe system SHOULD provide the ability to search, view, and contribute to local service registries that include providers, medical home practices or services, durable medical equipment (DME skilled nursing facilities (SNF social service programs, etc. and detail services, insurance affiliation, and preferred contact method for notes, referrals, and orders.Children with Special Healthcare NeedsNormative Statementsno
Req-461Support the addition or exclusion of patients from registries by authorized users2013 FormatThe system SHOULD support the addition or exclusion of patients from registries by authorized users and capture addition or exclusion criteria.Children with Special Healthcare NeedsNormative Statementsno
Req-457Support the capture of coded pediatric functional health status measures2013 FormatThe system SHALL support the capture of coded pediatric functional health status measures (e.g. ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-456Support the capture of coded age based, disease specific measures2013 FormatThe system SHALL support the capture of coded age based, disease specific measures used in the characterization and/or categorization of disease severity (e.g. Asthma: National Heart Lung and Blood Institute Asthma Severity Tool; depression; ADHDChildren with Special Healthcare NeedsNormative Statementsno
Req-602Document using standard assessments2013 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.
Children with Special Healthcare NeedsNormative Statementsno
Req-697Manage Practitioner/Patient Relationships2013 Format
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about...
STATEMENT: Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.
DESCRIPTION: This function addresses the ability to access and update current information about the relationships between caregivers and the patients. This information should be able to flow seamlessly between the different components of the system, and between the EHR system and other systems. Business rules may be reflected in the presentation of, and the access to this information. The relationship among providers treating a single patient will include any necessary chain of authority/responsibility.
Example: In a care setting with multiple providers, where the patient can only see certain kinds of providers (or an individual provider allow the selection of only the appropriate providers.
Example: The user is presented with a list of people assigned to a given practitioner and may alter the assignment as required - to a group, to another individual or by sharing the assignment.
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Children with Special Healthcare NeedsFunctionno
Req-749Manage Patient and Family Preferences2013 Format
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to...
STATEMENT: Capture and maintain patient and family preferences. DESCRIPTION: Patient and family preferences regarding issues such as language, religion, spiritual practices and culture may be important to the delivery of care. It is important to capture these so that they will be available to the provider at the point of care.
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Children with Special Healthcare NeedsHeaderno
Req-739Support for Monitoring Response Notifications Regarding a Specific Patient’s Health2013 Format
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that...
STATEMENT: In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.
DESCRIPTION: Identifies that expected follow-up for a specific patient event (e.g., follow up to error alerts or absence of an expected lab result has not occurred and communicate the omission to appropriate care providers in the chain of authority. The notification process requires a security infrastructure that provides the ability to match a care provider's clinical privileges with the clinical requirements of the notification.
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Children with Special Healthcare NeedsFunctionno
Req-730Flag special healthcare needs2013 FormatThe system SHALL support the flagging of individuals with special healthcare needs or complex conditions, to facilitate care management, decision support, and reporting.Children with Special Healthcare NeedsNormative Statementsno
Req-732Ability to search service registries2013 FormatService registry entries SHOULD be searchable by name, location, service categories provided, and/or parent organization.Children with Special Healthcare NeedsNormative Statementsno
Req-1067Support incremental interoperability standards2013 FormatThe system SHOULD support incremental interoperability standards between EHRs and school management systems, health service providers, and governmental agencies.Children with Special Healthcare NeedsNormative Statementsno
Req-1064Ability to send non-medication orders, referrals, and updates to receiving systems2013 Format
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company,...
The system SHOULD provide the ability to send non-medication orders, referrals, and updates to receiving systems, such as laboratory information systems (LIS radiology information systems (RIS dietary, ancillary service providers, durable medical equipment (DME company, home care provider, case management, and mental, dental, and visual health services, when standard interfaces are available.
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Children with Special Healthcare NeedsNormative Statementsno
Req-1065Ability to route and track patient disease management plans, etc. to recipients in local registry2013 FormatThe system MAY provide the ability to version, route and track patient disease management plans, school medication administration forms, early intervention and WIC referrals, etc. to recipients in local service provider registry by preferred routing method (e.g. fax or electronicChildren with Special Healthcare NeedsNormative Statementsno
Req-1058Manage language preferences2013 FormatThe system SHALL capture the child's preferred language, including sign language (separately from that of the parent/caregiver and whether an interpreter is necessary.Children with Special Healthcare NeedsNormative Statementsno
Req-1062DME and nursing needs2013 FormatThe system SHALL capture Durable Medical Equipment (DME and nursing needs for the child with identification of age-appropriate resources and orderables.Children with Special Healthcare NeedsNormative Statementsno
Req-1060Clinical decision support for code status2013 FormatThe system SHOULD support the ability to prompt for the provider (appropriate to local processes and workflow to discuss code status with the parent/guardian of a medically complex child with special health care needs upon an initial health & physical evaluation.Children with Special Healthcare NeedsNormative Statementsno
Req-1061Hospice and palliative care needs2013 FormatThe system SHALL capture hospice and palliative care needs for the child with identification of age-appropriate resources.Children with Special Healthcare NeedsNormative Statementsno
Req-2014Flag special healthcare needs2015 Priority ListThe system shall support the ability for providers to flag or unflag individuals with special health care needs or complex conditions who may benefit from care management, decision support, and care planning; and shall support reporting.Children with Special Healthcare NeedsNormative Statementyes
Req-2022DME and nursing needs2015 Priority ListThe system shall capture Durable Medical Equipment (DME and nursing needs for the child with identification of age-appropriate resources and orderables.Children with Special Healthcare NeedsNormative Statementyes
Req-289Care Plans, Treatment Plans, Guidelines, and Protocols2013 FormatMaintain Care Plans, Treatment Plans, Guidelines and Protocols.Children with Special Healthcare Needs, EPSDT, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-1063Support the population of patient registries based on specific data2013 FormatThe system SHALL support the population of patient registries based on specific demographic information (including age clinical findings, diagnoses, medications, and financial/payor criteria.Children with Special Healthcare Needs, Genetic information, ImmunizationsNormative Statementsno
Req-285Administrative and Financial2013 FormatSystem supports Administrative and Financial functions.Children with Special Healthcare Needs, Genetic information, Registry Linkages, Specialized Scales/Scoring, Well Child/Preventive CareHeaderno
Req-867Display BMI data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-850Display head circumference on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-862Ability to record tare weight for DME2013 FormatThe system SHALL allow recording of tare weight for durable medical equipment such as wheelchairs and walkers to facilitate easy weighing of children with special needs.Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-860Display weight data on population-specific growth charts2013 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.
Children with Special Healthcare Needs, Growth DataNormative Statementsno
Req-577Measurement, Monitoring, and Analysis2013 FormatSTATEMENT: Support measurement and monitoring of care for relevant purposesChildren with Special Healthcare Needs, Growth Data, Primary Care Management, Quality Measures, Well Child/Preventive CareHeaderno
Req-855Weight2013 FormatWeight is typically measured in newborns and then at every patient encounter.Children with Special Healthcare Needs, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
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-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-287Preferences, Directives, Consents and Authorizations2013 FormatMaintain preferences, directives, consents and authorizations.
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Headerno
Req-256Manage Consents and Authorizations2013 Format
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment...
STATEMENT: Create, maintain, and verify patient decisions such as informed consent for treatment and authorization/consent for disclosure when required.
DESCRIPTION: Decisions are documented and include the extent of information, verification levels and exposition of treatment options. This documentation helps ensure that decisions made at the discretion of the patient, family, or other responsible party govern the actual care that is delivered or withheld.
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Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology...
Children with Special Healthcare Needs, Parents and Guardians and Family Relationship Data, Primary Care Management, Security and Confidentiality, Special Terminology and Information
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Functionno
Req-471Access to patient data-specific materials2013 FormatThe system SHOULD provide access to display and print relevant provider/layperson treatment procedure standards/training; medical/psychological/behavioral condition education materials; and related management guidelines based on coded patient data in the system (e.g. InfobuttonChildren with Special Healthcare Needs, Patient Portals - PHRNormative Statementsno
Req-262Manage Patient-Specific Care and Treatment Plans2013 Format
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the...
STATEMENT: Provide administrative tools for healthcare organizations to build care plans, guidelines and protocols for use during patient care planning and care.
DESCRIPTION: Care plans, guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. Transfer of treatment and care plans may be implemented electronically using, for example, templates, or by printing plans to paper.
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Children with Special Healthcare Needs, Patient Portals - PHR, Primary Care Management, Quality Measures, Well Child/Preventive CareFunctionno
Req-458Coded disease measure goals and thresholds2013 FormatThe system SHOULD capture/calculate coded individualized disease measure goals and thresholds for modifying care (e.g. peak flow, FEV1, HgA1c, or behavioral goals used in self-care and inpatient treatment plansChildren with Special Healthcare Needs, Primary Care Management, Quality MeasuresNormative Statementsno
Req-565Orders, Referrals, Results and Care Management2013 FormatSystem supports Orders, Referrals, Results and Care Management.Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareHeaderno
Req-564Support for Referral Process2013 Format
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof...
STATEMENT: Evaluate referrals within the context of a patient's healthcare data.
DESCRIPTION: When a healthcare referral is made, health information, including pertinent clinical and behavioral health results, demographic and insurance data elements (or lack thereof are presented to the provider. Standardized or evidence based protocols for appropriate workup prior to referral may be presented.
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Children with Special Healthcare Needs, Primary Care Management, Well Child/Preventive CareFunctionno
Req-1059Code status for children with special healthcare needs2013 FormatThe system MAY selectively include code status on the Health & Physical Evaluation template for a child designated as medically complex and/or with special health care needs.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsno
Req-1057Use and search of pediatric diagnosis codes2013 FormatThe system SHALL support the use and search of a broad selection of pediatric diagnosis codes and code sets, when available, such as by specialty, subspecialty or organ system.Children with Special Healthcare Needs, Special Terminology and InformationNormative Statementsyes
Req-109Support for Population Health2013 FormatSystem supports Population Health.Children with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-283Manage Health Information to Provide Decision Support2013 FormatSystem manages health information to provide Decision SupportChildren with Special Healthcare Needs, Well Child/Preventive CareHeaderno
Req-1066Caregiver contact information for children with special healthcare needs2013 FormatThe system SHALL provide the ability to capture the names and contact information for primary provider, case managers, and subspecialists that follow a child with special healthcare needs, including their contact information.Children with Special Healthcare Needs, Well Child/Preventive CareNormative Statementsno
Req-122Manage Patient Clinical Measurements2013 Format
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of...
STATEMENT: Capture and manage patient clinical measures, such as vital signs, as discrete patient data.
DESCRIPTION: Patient measures such as vital signs are captured and managed as discrete data to facilitate reporting and provision of care. Other clinical measures (such as expiratory flow rate, size of lesion, etc. are captured and managed, and may be discrete data.
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EPSDT, Growth Data, Medication Management, Primary Care Management, Specialized Scales/Scoring, Well Child/Preventive CareFunctionno
Req-269Support for Standard Care Plans, Guidelines, Protocols2013 Format
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and...
STATEMENT: Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.
DESCRIPTION: Before they can be accessed upon request (e.g., in DC 1.6.1 standard care plans, protocols, and guidelines must be created. These documents may reside within the system or be provided through links to external sources, and can be modified and used on a site specific basis. To facilitate retrospective decision support, variances from standard care plans, guidelines, and protocols can be identified and reported.
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EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareFunctionno
Req-290Support for Condition Based Care and Treatment Plans, Guidelines, Protocols2013 FormatSystem supports Condition Based Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-291Care and Treatment Plans, Guidelines and Protocols2013 FormatSystem maintains Care and Treatment Plans, Guidelines and Protocols.EPSDT, Growth Data, Primary Care Management, Well Child/Preventive CareHeaderno
Req-690Recommend required immunizations per schedules2013 FormatThe system SHALL provide the ability to recommend required immunizations, and when they are due, during an encounter based on widely accepted immunization schedules.EPSDT, ImmunizationsNormative Statementsno
Req-265Notifications and Reminders for Preventive Services and Wellness2013 Format
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are...
STATEMENT: Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.
DESCRIPTION: The provider can generate notifications to patients regarding activities that are due or overdue and these communications can be captured. Examples include but are not limited to time sensitive patient and provider notification of: follow-up appointments, laboratory tests, immunizations or examinations. The notifications can be customized in terms of timing, repetitions and administration reports. E.g. a PAP test reminder might be sent to the patient two months prior to the test being due, repeated at three month intervals, and then reported to the administrator or clinician when nine months overdue.
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EPSDT, Newborn Screening, Patient Portals - PHR, Well Child/Preventive CareFunctionno
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-1086Age-appropriate notifications2013 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.
EPSDT, Patient Portals - PHR, Well Child/Preventive CareNormative Statementsno
Req-1289Blood-lead testing2013 FormatThe system SHOULD alert when blood-lead testing is needed.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1286Abnormal screen follow-up2013 FormatThe system SHOULD provide prompts to follow-up after an abnormal screening result.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-1287Referral for dental services2013 FormatThe system SHOULD facilitate a dental referral according to the appropriate periodicity schedule (generally by age one or at eruption of the first tooth, and biannually thereafter or whenever indicated by abnormal findings.EPSDT, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-639Access to age-specific guidelines2013 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.
EPSDT, Well Child/Preventive CareNormative Statementsyes
Req-978Physical exam screening results2013 FormatThe system SHALL allow documentation of the presence or absence of age- and gender-specific physical exam findings.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-983Prompts for re-screening2013 FormatThe system SHOULD provide prompts regarding re-screening.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-972Age-specific preventive encounters2013 FormatThe system SHALL support age-specific preventive well-child encounters with content based on age-appropriate recommendations such as Medicaid EPSDT (Early and Periodic Screening, Diagnostic & Treatment and Bright Futures periodicity schedules.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1085Prioritized list of recommended preventive care2013 FormatThe system SHOULD provide a prioritized list of recommended age specific preventive care based on a patient's previously completed preventive care, documented risk factors, and interest in specific preventive care.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1073Age-specific screening forms2013 FormatThe system SHOULD support age-specific screening forms, including forms with content based on age-appropriate recommendations such as state-designated EPSDT (Early and Periodic Screening, Diagnostic & Treatment tools and Bright Futures Guidelines.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1290EPSDT reporting2013 FormatThe system SHOULD be able to generate reports of recommended EPSDT (Early and Periodic Screening, Diagnostic & Treatment services to support annual EPSDT reporting requirements.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-1288Fluoride varnish and dental sealants2013 FormatThe system SHOULD alert when application of fluoride varnish or dental sealant is due. and support management and tracking of this service whether provided by the primary care provider or through a referral.EPSDT, Well Child/Preventive CareNormative Statementsno
Req-2009Allow unknown patient sex2015 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.
Genetic information, Birth Information, Prenatal ScreeningNormative Statementyes
Req-507Import / export data with Surgeon General’s Family Health History Tool2013 Format
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7...
The system MAY import and export a family health history from and to the Surgeon General's Family Health History Tool using the HITSP IS08 / C90 Clinical Genomics Decision Support Tool based on the HL7 v3 clinical genomics model with data mapping to the family history section of the HITSP C83 CCD content module for family history.
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Genetic information, Parents and Guardians and Family Relationship Data, Primary Care Management, Well Child/Preventive CareNormative Statementsno
Req-110Capture patient vital signs2013 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.
Growth DataNormative Statementsyes
Req-111Statistics for growth chart 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.
Growth DataNormative Statementsno
Req-119Documentation for patient educational material2013 FormatThe system SHALL provide the ability to document that the educational material was reviewed with the patient and/or patient representative and their comprehension of the material.Growth DataNormative Statementsno
Req-118Support for growth data assessment and planning2013 FormatThe system SHOULD provide access to display and print accepted anthropometry procedure standards/training; provider/layperson growth chart interpretation guides; and related disease management guidelines.Growth DataNormative Statementsno
Req-117Calculate growth velocity2013 FormatThe system SHOULD calculate growth velocity between two points on the growth chart selected by the user.Growth DataNormative Statementsno
Req-116Select growth data reference standards2013 FormatThe system SHALL allow user selection of appropriate reference standards (e.g. CDC, WHO, Down's, or Turner's Syndrome display corresponding growth reference percentile curves/calculations, and denote the growth reference used in calculation and display.Growth DataNormative Statementsyes
Req-115Childhood obesity statistics2013 FormatSystem MAY store and display waist circumference and hip circumference and calculate/display waist to hip ratio in patients identified with obesity or cardiovascular risk.Growth DataNormative Statementsno
Req-113Indicate information collected at Point of Care2013 FormatThe system SHOULD indicate point of care of collected measures and/or allow filtering of values by point(s of care.Growth DataNormative Statementsno
Req-112Normative values for growth chart data2013 FormatThe system SHOULD calculate and display average weight for age, average height for age, and ideal/target weight for height (e.g. Waterlow methodGrowth DataNormative Statementsno
Req-126Growth and body composition data2013 FormatSystem supports recording of growth and body composition measures, calculations, conversions, normal ranges, and trending.Growth DataHeaderno
Req-121View new data on growth chart before confirming2013 FormatUser MAY be able to view values being entered plotted on growth chart prior committing to system.Growth DataNormative Statementsno
Req-120Immediate alerts for abnormal growth values2013 FormatThe system SHALL support alerting at the time of value entry for values outside of the probable range and heights less than previous measures.Growth DataNormative Statementsno
Req-275Auditable Records2013 Format
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time...
STATEMENT: Provide audit capabilities for system access and usage indicating the author, the modification (where pertinent and the date and time at which a record was created, modified, viewed, extracted, or deleted. Date and Time stamping implies the ability to indicate the time zone where it was recorded (time zones are described in ISO 8601 Standard Time Reference Auditable records extend to information exchange, to audit of consent status management (to support Req-256 (HL7 ID: DC.1.3.3 and to entity authentication attempts. Audit functionality includes the ability to generate audit reports and to interactively view change history for individual health records or for an EHR-S.
DESCRIPTION: Audit functionality extends to security audits, data audits, audits of data exchange, and the ability to generate audit reports. Audit capability settings should be configurable to meet the needs of local policies. Examples of audited areas include:
- Security audit, which logs access attempts and resource usage including user login, file access, other various activities, and whether any actual or attempted security violations occurred
- Data audit, which records who, when, and by which system an EHR record was created, updated, translated, viewed, extracted, or (if local policy permits deleted. Audit-data may refer to system setup data or to clinical and patient management data
- Information exchange audit, which records data exchanges between EHR-S applications (for example, sending application; the nature, history, and content of the information exchanged and information about data transformations (for example, vocabulary translations, reception event details, etc.
- Audit reports should be flexible and address various users' needs. For example, a legal authority may want to know how many patients a given healthcare provider treated while the provider's license was suspended. Similarly, in some cases a report detailing all those who modified or viewed a certain patient record
- Security audit trails and data audit trails are used to verify enforcement of business, data integrity, security, and access-control rules
-There is a requirement for system audit trails for the following events:
>Loading new versions of, or changes to, the clinical system;
>Loading new versions of codes and knowledge bases;
>Taking and restoring of backup;
>Changing the date and time where the clinical system allows this to be done;
>Archiving any data;
>Re-activating of an archived patient record;
>Entry to and exiting from the clinical system;
>Remote access connections including those for system support and maintenance activities
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Growth DataFunctionno
Req-426Provide unit conversions calculation and display during data entry and display2013 FormatThe system SHALL provide unit conversions calculation and display during data entry and display (e.g. lbs/kgGrowth DataNormative Statementsno
Req-619BMI and growth velocity2013 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.
Growth DataNormative Statementsno
Req-622Growth chart 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.
Growth DataNormative Statementsno
Req-626Bone age2013 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.
Growth DataNormative Statementsno
Req-624Mid-parental height2013 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.
Growth DataNormative Statementsno
Req-630Print growth chart2013 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.
Growth DataNormative Statementsno
Req-629Normal data range per Tanner stage2013 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.
Growth DataNormative Statementsno
Req-628Height input2013 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.
Growth DataNormative Statementsno
Req-666Audit trails2013 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.
Growth DataNormative Statementsno
Req-720Support unit conversion during data entry and display2013 FormatThe system SHALL provide unit conversions calculation and display during data entry and data display (e.g. lbs/kgGrowth DataNormative Statementsno
Req-723Ability to incorporate risk factors and/or anticipatory guidance2013 FormatThe system MAY incorporate risk factors and/or anticipatory guidance relevant to body composition, age, and gender into display/printout of growth charts.Growth DataNormative Statementsno
Req-724Support for population, maintenance, and export of registries2013 FormatThe system SHOULD support the population, maintenance, and export of registries including patients with significant anthropometric findings and related disease risk factors.Growth DataNormative Statementsno
Req-725Support for population level reporting2013 FormatThe system SHOULD support population level reporting of collected and derived measures of growth and body composition and related clinical and demographic information.Growth DataNormative Statementsno
Req-868Alert to obtain height when BMI required2013 FormatThe system MAY allow alerting to indicate the need to obtain a height when a BMI is required (by policy or guidelineGrowth DataNormative Statementsno
Req-869Height Velocity2013 FormatAssessment of a child's growth rate by height.Growth DataFunctionno
Req-870Display growth velocity data on normative growth chart2013 FormatThe system SHALL calculate growth velocity from height data, and plot it on normative curves provided by agencies such as CDC and WHO.Growth DataNormative Statementsno
Req-871Display bone age and growth velocity data together2013 FormatThe system SHOULD allow inclusion of bone age data on the same display as the growth velocity data.Growth DataNormative Statementsno
Req-872Anthropometric prescribing support2013 FormatMost pediatric drug dosing is weight-based. Sometimes drug dosing is based on body surface area or other anthropometric measures (e.g., oncology drugsGrowth DataHeaderno
Req-873Support exporting of anthropometric data2013 FormatThe system MAY export anthropometric data to the drug prescribing module to provide additional support.Growth DataNormative Statementsno
Req-874Predictive growth and clinical context2013 FormatPredictive growth and clinical contextGrowth DataHeaderno
Req-875Display predictive growth curves2013 FormatThe system MAY display predictive growth curves or growth targets based on mid-parental height or other techniques.Growth DataNormative Statementsno
Req-876Display clinical context for each point on growth chart2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Growth DataNormative Statementsno
Req-877Editing of Data2013 FormatData editing aspects of the system.Growth DataFunctionno
Req-878Correct growth data2013 FormatThe system SHALL have a process to correct growth data. This process shall include a method to track changes.Growth DataNormative Statementsno
Req-879Correct growth data directly from growth chart2013 FormatThe system SHOULD allow the user to correct growth data directly from the growth chart, by interacting directly with the graphical data point, rather than having to first go to a tabular (flowsheet representation.Growth DataNormative Statementsno
Req-854Display length/height data on population-specific growth charts2013 FormatThe system MAY display length/height data on selected population-specific growth charts (e.g., children with Down syndrome or a particular ethnicityGrowth DataNormative Statementsno
Req-858Support precise measurement units in both metric and English system2013 FormatThe system SHALL have similar levels of precision in both the Metric and English systems for recording weight.Growth DataNormative Statementsno
Req-857Weight precision: 2 months and older2013 FormatThe system SHALL record weight in kilograms with up to two decimal points in children after 2 months of life or 10 kg, whichever comes later.Growth DataNormative Statementsno
Req-856Weight precision: 2 months and younger2013 FormatThe system SHALL record weight in kilograms with up to 3 decimal points (i.e., in grams through 2 months of life or 10 kg, whichever comes later.Growth DataNormative Statementsno
Req-839Display growth charts2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Growth DataNormative Statementsyes
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-962Display head circumference data on growth charts2013 FormatThe system SHALL be able to display all recorded head circumference data on the sex-specific growth chart.Growth DataNormative Statementsno
Req-1052Compare Growth Charts2013 FormatThe system MAY allow for the display of multiple growth charts (such as for weight, length or height and head circumference in a single screen or view.Growth DataNormative Statementsno
Req-2002Record all vital signs and growth parameters precisely2015 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.
Growth DataNormative Statementyes
Req-2003Provide unit conversions calculation and display during data entry and display2015 Priority ListThe system shall provide unit conversions calculation and display during data entry and display (e.g., lb/kg as well as appropriate level of precision (e.g., mm or quarter inch for length/heightGrowth DataNormative Statementyes
Req-2042Support growth charts for children2015 Priority List
The system shall support display of growth charts that plot selected growth parameters such as height, weight, head circumference, and BMI (entered with appropriate precision or computed as described in Req-2019...
The system shall support display of growth charts that plot selected growth parameters such as height, weight, head circumference, and BMI (entered with appropriate precision or computed as described in Req-2019 along with appropriate sets of norms provided by the CDC or in a compatible tabular format (typically based on Lambda-Mu-Sigma [LMS] curve fitting computational method
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Growth DataNormative Statementyes
Req-295Health Record Information and Management2013 Format
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to...
STATEMENT: Manage EHR information across EHR-S applications by ensuring that clinical information entered by providers is a valid representation of clinical notes; and is accurate and complete according to clinical rules and tracking amendments to clinical documents. Ensure that information entered by or on behalf of the patient is accurately represented.
DESCRIPTION: Since EHR information will typically be available on a variety of EHR-S applications, an EHR-S must provide the ability to access, manage and verify accuracy and completeness of EHR information, maintain the integrity and reliability of the data, and provide the ability to audit the use of and access to EHR information.
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Growth Data, Prenatal Screening, Well Child/Preventive CareHeaderno
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-959Adjust head circumference display for prematurity2013 FormatThe system SHALL be able to display head circumference adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsyes
Req-961Adjust weight display for prematurity2013 FormatThe system SHOULD be able to display weight adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
Req-960Adjust length display for prematurity2013 FormatThe system SHOULD be able to display length adjusted for the degree of prematurity by subtracting the number of weeks premature the individual was born from each plot point during the first two years of life. The growth chart should reflect that this plot was corrected for prematurity.Growth Data, Primary Care ManagementNormative Statementsno
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-851Length/Height2013 FormatLength is typically measured in newborns and then at every well-child visit through 36 months of life. Afterwards, height is typically recorded. Length/height may also be measured at other times based on clinician concern.Growth Data, Primary Care Management, 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-627User Interface preferences2013 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.
Growth Data, Specialized Scales/ScoringNormative Statementsno
Req-864Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal place at every well-child visit beginning at 24 months of life.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-865Calculate BMI to one decimal place2013 FormatThe system SHALL calculate body mass index (BMI to one decimal point at any age based on system query.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-866Display BMI data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display body mass index (BMI data on both the sex-specific CDC and WHO growth charts.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-848Record head circumference precisely2013 FormatThe system SHALL record head circumference at least to the half centimeter, or quarter inch, based on user preference, and record the date of measure.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-853Display length/height data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded length/height data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-852Measure length/height precisely2013 FormatThe system SHALL record length/height at least to the half centimeter, or quarter inch, based on user preference, whether the measure was length or height, and record the date of measure.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-859Display weight data on CDC and WHO growth chart2013 FormatThe system SHALL be able to display all recorded weight data on the sex-specific CDC and WHO growth chart.Growth Data, Well Child/Preventive CareNormative Statementsno
Req-861Record clothes/diaper status when weighed2013 FormatThe system SHALL record whether clothes or diaper were on when weighed.Growth Data, Well Child/Preventive CareNormative 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-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-2019Record Gestational Age Assessment and Persist in the EHR2015 Priority ListThe system shall capture and display assigned gestational age as well as the diagnosis of SGA=Small for Gestational Age or LGA=Large for Gestational Age when appropriate.Growth Data, Well Child/Preventive CareNormative Statementyes
Req-443Integrated immunizations reporting2013 FormatThe EHR SHOULD allow an integrated view of what immunizations are due or past due.ImmunizationsNormative Statementsno
Req-608Immunizations based on risk 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.
ImmunizationsNormative Statementsno
Req-609Data pertinent to immunization administration2013 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.
ImmunizationsNormative Statementsno
Req-612Update immunization schedule on demand2013 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.
ImmunizationsNormative Statementsno
Req-599Discrete immunization 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.
ImmunizationsNormative Statementsyes
Req-601Immunization consent status2013 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.
ImmunizationsNormative Statementsno
Req-657Record vaccine refusal reasons2013 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.
ImmunizationsNormative Statementsno
Req-719Interchange Agreements2013 Format
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION:...
STATEMENT: Support interactions with entity directories to determine the address, profile and data exchange requirements of known and/or potential partners.
Use the rules of interaction specified in the partner's interchange agreement when exchanging information.
DESCRIPTION: Systems that wish to communicate with each other, must agree on the parameters associated with that information exchange. Interchange Agreements allow an EHR-S to describe those parameters/criteria.
An EHR-S can use the entity registries to determine the security, addressing, and reliability requirements between partners.
An EHR-S can use this information to define how data will be exchanged between the sender and the receiver.
Discovery of interchange services and capabilities can be automatic.
For example:
- A new application can automatically determine a patient demographics source using a Universal Description and Discovery Integration (UDDI for source discovery, and retrieve the Web Services Description Language (WSDL specification for binding details.
- Good Health Hospital is a member of AnyCounty LabNet, for sharing laboratory results with other partners. Good Health Hospital periodically queries LabNet's directory (UDDI to determine if additional information providers have joined LabNet. When new information providers are discovered, the Good Health IT establishes the appropriate service connections based upon the Service Description (WSDL
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ImmunizationsFunctionno
Req-1119Multiple views of the immunization record2013 FormatThe system SHOULD provide the ability to display different views of a patient's immunization records, allowing users to specify data fields in the view.ImmunizationsNormative Statementsno
Req-1118Manage immunization data for quality measures2013 FormatThe system SHALL provide the ability to manage (search, retrieve, display, sort/filter, calculate immunization data to determine immunization rates (and other quality measures for practices and subsets (by provider, by care group, by patient population, age groups, etc.ImmunizationsNormative Statementsno
Req-1113Capture vaccine administration data from multiple input tools2013 FormatThe system SHOULD provide the ability to capture vaccine administration data from multiple input tools such as keyboard, bar-coding and radio-frequency identification devices.ImmunizationsNormative 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-1109Manage immunization inventory2013 FormatManage immunization inventoryImmunizationsFunctionno
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-1111Link patient record to immunization inventory2013 FormatThe system SHOULD provide the ability to link to a vaccine inventory (formulary for information about (immediately available vaccine doses (including brands, products, number of doses, dates of acquisition, and dates of expirationImmunizationsNormative Statementsno
Req-1110Predict practice-level immunization needs2013 FormatThe system MAY provide the ability to estimate/determine the number of types and doses of immunizations that will be required by a practice over a given period of time going forward (1 month, 3 months, etc. based on patient lists and demographics.ImmunizationsNormative Statementsno
Req-1105Link vaccine doses to specific patients2013 FormatLink vaccine doses to specific patientsImmunizationsFunctionno
Req-1104Immunization procurement and inventory management2013 FormatImmunization procurement and inventory managementImmunizationsHeaderno
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-1106Link vaccine dose to patient record2013 FormatThe system SHOULD provide the ability to link each individual vaccine dose/identifier to a specific patient record by patient ID, prescribing provider, planned date of administration, patient insurance , and vaccine identifiers, including type (antigen combination brand, lot number, and dose number.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-1132Identify patients underinsured for immunizations2013 FormatThe system SHOULD provide the ability to identify patients who are uninsured or underinsured for immunizations, such as those that are eligible for Vaccines for Children (VFC and S-CHIP/Medicaid.ImmunizationsNormative Statementsno
Req-1133Document reason for non-vaccination2013 FormatThe system SHALL provide the ability to document reasons for non-vaccination that MAY include: the prescriber, the patient, and the reason the vaccine dose was not given.ImmunizationsNormative Statementsno
Req-1130Guideline based decision support for immunization ordering2013 FormatThe system SHALL provide real-time decision support for ordering immunizations for treatment and prophylaxis (such as tetanus, rabies and hepatitis A/B, etc. based on guidelines.ImmunizationsNormative Statementsno
Req-1131Vaccine reminders2013 FormatThe system MAY provide the ability to link to (and display vaccine dose reminders from recognized health maintenance standards.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-1129Immunity data as vaccine contraindication2013 FormatThe system SHALL provide the ability to link to historical and/or laboratory data that documents a patient's immunity as a contraindication to ordering/administering a vaccine dose.ImmunizationsNormative Statementsno
Req-1126Timely decision support when ordering vaccines2013 Format
The system SHALL enable timely decision support (recommendations for specific antigens when ordering vaccine dose(s for an individual patient, based on a current child health immunization schedules, which may include the patient's immunization history (age,...
The system SHALL enable timely decision support (recommendations for specific antigens when ordering vaccine dose(s for an individual patient, based on a current child health immunization schedules, which may include the patient's immunization history (age, vaccines received, including date of last previous vaccination b the patient's demographics (date of birth and clinical history (current weight, allergies, medications, problem lists, and laboratory test results including contraindications to vaccine components, and c an entered date (default date is the time the vaccine is ordered, i.e. Now
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ImmunizationsNormative Statementsyes
Req-1127Show available dose options for recommended antigens2013 FormatThe system SHOULD provide the ability to display vaccine dose (brand/product/price options for recommended antigens, including combination vaccines given a patient's immunization history and demographic and clinical data.ImmunizationsNormative Statementsno
Req-1124Support for ordering immunizations2013 FormatSupport for ordering immunizationsImmunizationsFunctionno
Req-1125Disseminate immunization news to prescribers2013 FormatThe system SHOULD provide the ability to capture and disseminate just-in-time news about vaccine shortages and recalls to prescribers at the point of ordering/prescribing. The news can come from regulatory agencies, supply chain stakeholders and institutional/practice administrators.ImmunizationsNormative Statementsno
Req-1120Specify standard views of immunization information2013 FormatThe system SHOULD provide the ability to specify standard views of patient immunization information for each vaccine dose administration. These SHOULD be able to include patient-specific data, such as patient age on dates of administration, and SHOULD support templates, such as brief (card view and detailed (all information views.ImmunizationsNormative Statementsno
Req-1121Annotate immunization record2013 FormatThe system SHOULD provide the ability to annotate a patient immunization record.ImmunizationsNormative 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-1144Exchange immunization data with PHRs2013 FormatThe system MAY exchange immunization data with personal health records (PHRsImmunizationsNormative Statementsno
Req-1143Exchange immunization information with external sources2013 FormatThe system SHOULD exchange immunization data with external sources (e.g. hospitals, newborn nurseries, emergency departments, and retail-based clinics about vaccines administered to patients. The exchange SHOULD use an established immunization messaging standard.ImmunizationsNormative Statementsno
Req-1137Printed Vaccine Information Statement Sheet2013 FormatThe system SHALL provide the ability to produce official paper Vaccine Information Statement Sheets as required by Federal Law to be given to caregivers or patients at the point and time of vaccine administration.ImmunizationsNormative Statementsno
Req-1136Context for recommended immunizations not given2013 FormatThe system SHALL provide the ability to capture and output (documentation and display vaccine doses that have been recommended by the system but not ordered or administered (including the date of recommendation and reason for not ordering or administering.ImmunizationsNormative Statementsyes
Req-272Support for Patient Specific Dosing and Warnings2013 Format
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g....
STATEMENT: Identify and present appropriate dose recommendations based on known patient- conditions and characteristics at the time of medication ordering.
DESCRIPTION: The clinician is alerted to drug-condition interactions and patient specific contraindications and warnings e.g. pregnancy, breast-feeding or occupational risks, hepatic or renal insufficiency. The preferences of the patient may also be presented e.g. reluctance to use an antibiotic. Additional patient parameters, such as age, gestation, height, weight, and body surface area (BSA shall also be incorporated.
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Immunizations, Medication ManagementFunctionno
Req-292Support for Medication and Immunization Ordering2013 FormatSystem supports Medication and Immunization Ordering.Immunizations, Medication ManagementHeaderno
Req-1116Vaccine administration messages to billing system2013 FormatThe system SHOULD send standard messages to the practice management/billing system that include vaccine-specific administration codes.Immunizations, Medication ManagementNormative 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-1114Integrate vaccine administration with other systems2013 FormatThe system MAY integrate vaccine dose administration with vaccine/medication management systems and practice management/billing systems.Immunizations, Medication ManagementNormative Statementsno
Req-273Support for Medication and Immunization Administration2013 Format
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To...
STATEMENT: Alert providers to potential administration errors (such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of safe and accurate medication administration and support medication administration workflow.
DESCRIPTION: To reduce medication errors at the time of administration of a medication, the patient is positively identified; checks on the drug, the dose, the route and the time are facilitated. Documentation is a by-product of this checking; administration details and additional patient information, such as injection site, vital signs, and pain assessments, are captured.
Access to drug monograph information may be provided to allow providers to check details about a drug and enhance patient education. Workflow for medication administration is supported through prompts and reminders regarding the "window" for timely administration of medications.
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Immunizations, Medication Management, Registry LinkagesFunctionno
Req-293Medication and Immunization Management2013 FormatSystem manages Medications and ImmunizationsImmunizations, Medication Management, Registry LinkagesHeaderno
Req-249Health Record Output2013 Format
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare...
STATEMENT: Support the definition of the formal health record, a partial record for referral purposes, or sets of records for other necessary disclosure purposes.
DESCRIPTION: Provide hardcopy and electronic output that fully chronicles the healthcare process, supports selection of specific sections of the health record, and allows healthcare organizations to define the report and/or documents that will comprise the formal health record for disclosure purposes. A mechanism should be provided for both chronological and specified record element output. This may include defined reporting groups (i.e. print sets For example: Print Set A = Patient Demographics, History & Physical, Consultation Reports, and Discharge Summaries. Print Set B = all information created by one caregiver. Print Set C = all information from a specified encounter. An auditable record of these requests and associated exports may be maintained by the system. This record could be implemented in any way that would allow the who, what, why and when of a request and export to be recoverable for review. The system has the capability of providing a report or accounting of disclosures by patient that meets in accordance with scope of practice, organizational policy and jurisdictional law.
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Immunizations, Patient Identifier, Registry Linkages, Security and Confidentiality, Well Child/Preventive CareFunctionno
Req-1102Controlled access to registries data2013 FormatThe system MAY enable controlled access to and display of data contained in registries such as immunizations.Immunizations, Patient Portals - PHRNormative Statementsno
Req-1097Patient and Caregiver Views2013 FormatThe child's clinical information should be accessible by the child, parents, guardians, caregivers and other consumers to enable assessment of compliance with school or leisure activity requirements. In addition, it should be usable by caregivers to assure care appropriateness and quality.Immunizations, Patient Portals - PHRFunctionno
Req-266Present Ad Hoc Views of the Health Record2013 Format
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters,...
STATEMENT: Subject to jurisdictional laws and organizational policies related to privacy and confidentiality, present customized views and summarized information from a patient's comprehensive EHR. The view may be arranged chronologically, by problem, or other parameters, and may be filtered or sorted.
DESCRIPTION: A key feature of an electronic health record is its ability to support the delivery of care by enabling prior information to be found and meaningfully displayed. EHR systems should facilitate search, filtering, summarization, and presentation of available data needed for patient care. Systems should enable views to be customized, for example, specific data may be organized chronologically, by clinical category, or by consultant, depending on need. Jurisdictional laws and organizational policies that prohibit certain users from accessing certain patient information must be supported.
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Immunizations, Patient Portals - PHR, Primary Care Management, Well Child/Preventive CareFunctionno
Req-107Standards Based Interoperability2013 Format
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified...
Provide automated health care delivery processes and seamless exchange of clinical, administrative, and financial information through standards-based solutions.
Interoperability standards enable an EHR-S to operate as a set of applications. This results in a unified view of the system where the reality is that several disparate systems may be coming together.
Interoperability standards also enable the sharing of information between EHR systems, including the participation in regional, national, or international information exchanges.
Timely and efficient access to information and capture of information is promoted with minimal impact to the user.
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Immunizations, Prenatal Screening, Registry Linkages, School-Based LinkagesHeaderno
Req-611Synchronize immunization histories with registry2013 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.
Immunizations, Registry LinkagesNormative Statementsyes
Req-595Report adverse events2013 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.
Immunizations, Registry LinkagesNormative Statementsno
Req-673Report summaries: hard copy and electronic2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Immunizations, Registry LinkagesNormative Statementsno
Req-772Interchange Standards Versioning and Maintenance2013 Format
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its...
STATEMENT: Enable version control according to local policies to ensure maintenance of utilized interchange standards.
Version control of an interchange standard implementation includes the ability to accommodate changes as the source interchange standard undergoes its natural update process.

DESCRIPTION:
The life cycle of any given standard results in changes to its requirements. It is critical that an organization know the version of any given standard it uses and what its requirements and capabilities are.

For example, if the organization migrates to an HL7 v2.5 messaging standard, it may choose to take advantage of new capabilities such as specimen or blood bank information. The organization may find that certain fields have been retained for backwards compatibility only or withdrawn altogether. The EHR-S needs to be able to handle all of these possibilities.

Standards typically evolve in such a way as to protect backwards compatibility. On the other hand, sometimes there is little, or no, backwards compatibility when an organization may need to replace an entire standard with a new methodology. An example of this is migrating from HL7 v2 to HL7 v3.

Interchange standards that are backward compatible support exchange among senders and receivers who are using different versions. Version control ensures that those sending information in a later version of a standard consider the difference in information content that can be interchanged effectively with receivers, who are capable of processing only earlier versions. That is, senders need to be aware of the information that receivers are unable to capture and adjust their business processes accordingly.
Version control enables multiple versions of the same interchange standard to exist and be distinctly recognized over time.
Since interchange standards are usually periodically updated, concurrent use of different versions may be required.
Large (and/or federated organizations typically need to use different versions of an interchange standard to meet internal organizational interoperability requirements.
For example, the enterprise-wide standard might use HL7 v2.5 for Lab messages, but some regions of the enterprise might be at a lower level.
It should be possible to retire deprecated interchange standards versions when applicable business cycles are completed while maintaining obsolete versions. An example use of this is for possible claims adjustment throughout the claim's life cycle.
When interchange standards change over time, it is important that retrospective analysis and research correlate and note gaps between the different versions' information structures to support the permanence of concepts over time. An example use of this is the calculation of outcome or performance measures from persisted data stores where one version of a relevant interchange standard, e.g., CDA Release 1 captures the relevant data, e.g., discharge data, differently than CDA Release 2.
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Immunizations, Registry LinkagesFunctionno
Req-1134Transmit data on vaccine refusals to IIS2013 FormatThe system SHALL provide the ability to transmit data on vaccine refusals to Immunization Information Systems (IISs using an established and agreed upon messaging standard.Immunizations, Registry LinkagesNormative Statementsno
Req-1147IIS query responses in real-time2013 FormatThe system SHOULD provide the ability to receive real-time electronic query responses from IISs.Immunizations, Registry LinkagesNormative 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-1141Access to registries2013 FormatThe system SHOULD provide the ability to add, change, or remove access to registriesImmunizations, Registry LinkagesNormative Statementsno
Req-1140Send real-time queries on patients to IIS2013 FormatThe system SHALL provide the ability to send standard queries in real-time for immunization data regarding individual patients to Immunization Information Systems (IISsImmunizations, Registry LinkagesNormative Statementsno
Req-1139Use established immunization messaging standards2013 FormatThe system SHALL provide the ability to use established and agreed upon messaging standards to transmit and receive data from Immunization Information Systems (IISs and other Health Information Exchanges (HIEsImmunizations, Registry LinkagesNormative Statementsno
Req-1196Registry support for alerts2013 FormatThe system MAY access registry information (e.g. date of immunization, demographics of subject, name of vaccine to issue alerts within the EHR for specific patient cases.Immunizations, Registry LinkagesNormative Statementsno
Req-2011Synchronize immunization histories with registry2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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.
Immunizations, Registry LinkagesNormative Statementyes
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-781Information View2013 Format
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For...
STATEMENT: Support user-defined information views.

DESCRIPTION: Views of the information can be tailored for or by the user (or department or "job classification" for their presentation preferences, within local or facility established rules. For example, a nursing supervisor may elect or prefer to see summary data on all patients as the default view.
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Immunizations, Well Child/Preventive CareFunctionno
Req-1117Support for immunization information output management2013 FormatSupport for immunization information output managementImmunizations, Well Child/Preventive CareFunctionno
Req-1122Produce completed forms from EHR data2013 FormatThe system SHOULD produce paper and electronic forms (e.g. for camp, school, or child care and complete them with information from the patient record (both examination and immunization recordImmunizations, Well Child/Preventive CareNormative Statementsno
Req-1123Customized immunization reports2013 FormatThe system SHOULD provide the ability for users (based on role and authorization to specify reports based on EHR patient data on immunization status.Immunizations, Well Child/Preventive CareNormative Statementsno
Req-2027Produce completed forms from EHR data2015 Priority List
The system shall produce reports (e.g., for camp, school, or child care of a child's immunization history, including the following elements: child's name, date of birth and sex, date the report was produced, antigen administered,...
The system shall produce reports (e.g., for camp, school, or child care of a child's immunization history, including the following elements: child's name, date of birth and sex, date the report was produced, antigen administered, date administered, route of administration (when available and an indication of whether a vaccine was refused or contraindicated.
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Immunizations, Well Child/Preventive CareNormative Statementyes
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-884Alert for invalid dose computation data2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-887Drug contraindications in specific child populations2013 FormatThe system SHOULD provide the ability to detect contraindications in specific child populations (e.g. age groups or those with liver issues for individual medications and any combined pharmacotherapy and inform the user during ordering.Medication ManagementNormative Statementsno
Req-886Liquid drug prescriptions2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-888High risk drug combinations in children2013 FormatThe system SHALL provide the ability to detect high risk drug combination alerts specific to children and inform the user during ordering.Medication ManagementNormative Statementsyes
Req-891Alternative administration techniques2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-890Indicate common side effects2013 FormatThe system MAY provide the ability to indicate common side effects, including those unique to or more common in children, and inform the user during ordering.Medication ManagementNormative Statementsno
Req-893Documentation of compliance and refusal of care2013 FormatThe system MAY provide the ability to require documentation of information regarding patient compliance with prescribed treatment, including parent/guardian refusal of treatment.Medication ManagementNormative Statementsno
Req-892Child-appropriate doses in provider-specific medication lists2013 FormatThe system SHALL support child-appropriate dosing in provider specific medication lists ("favorites" including default route, dose, frequency, and quantity (e.g. accommodate weight-based doses such as <mg or mcg or gm>/kg/dose or <mg or mcg or gm>/kg/dayMedication ManagementNormative Statementsno
Req-894Require documentation of therapeutic labs2013 FormatThe system SHOULD provide the ability to require documentation of therapeutic labs or appropriate lab levels recommended for child dosing.Medication ManagementNormative Statementsno
Req-1006Support prescription details2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-1236Rounding for administrable doses2013 FormatThe system SHALL enable calculated doses (e.g. weight-based to be rounded to optimize administration convenience.Medication ManagementNormative Statementsyes
Req-1237Child-specific therapeutic substances2013 FormatThe system SHOULD enable the ordering of child-specific therapeutic substances, and support units appropriate to children.Medication ManagementNormative Statementsno
Req-1238Re-prescribe medications2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-1239Age-specific daily dose range checking2013 FormatThe system SHALL provide the ability to detect a daily dose that exceeds the recommended range for patient age or maximum recommended adult dose whichever is smaller.Medication ManagementNormative Statementsno
Req-1235Capture medication dosing details2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-1240Weight-specific daily dose range checking2013 FormatThe system SHALL inform the user when a daily dose has exceeded (or is planned to exceed the recommended range for patient size or maximum recommended adult dose, whichever is smaller.Medication ManagementNormative Statementsno
Req-1241Age- and weight-specific single dose range checking2013 FormatThe system SHALL provide the ability to detect a drug dose that falls outside the min-max range based on the patient's age, weight, and maximum recommended adult dose, for a single dose for the medication.Medication ManagementNormative Statementsyes
Req-1242Compounded drug dosage computations2013 Format
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-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-2005Closest available standardized dose2015 Priority ListThe system shall inform the ordering provider about the closest available standardized dose after calculating the dose based on patient age and weight and other factors.Medication ManagementNormative Statementyes
Req-2010Order blood products in pediatric units2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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 Statementyes
Req-2012Compute weight-based drug dosage2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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 Statementyes
Req-2035Rounding for administrable doses2015 Priority ListThe system shall enable calculated doses (e.g. weight-based to be rounded to optimize administration convenience.Medication ManagementNormative Statementyes
Req-2036Re-prescribe medications2015 Priority List
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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 Statementyes
Req-2037Age- and weight-specific single dose range checking2015 Priority ListThe system shall provide medication dosing decision support that detects a drug dose that falls outside the minimum-maximum range based on the patient's age, weight, and maximum recommended adult dose (if known or maximum recommended pediatric dose (if known for a single dose of the medication.Medication ManagementNormative Statementyes
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-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-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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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-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:
------
[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-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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
Lorem, ipsum, dolor, sit, amet, consectetur, adipiscing, elit, Ut, egestas, dolor, nec, ipsum, luctus, non, varius, felis, blandit, Quisque, facilisis, pellentesque, nisi, Sed, rutrum, sodales, nisl, Duis, mattis, ipsum, a, laoreet, pharetra, quam, eros, porta, nisl, eget, pellentesque, augue, purus, eu, nunc
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
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-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-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-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-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
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-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-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-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-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-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-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-1151Manually import maternal data into patient history2013 FormatWhen electronic access to the mother's data is not possible, the system SHOULD enable incorporation of selected maternal prenatal and perinatal data by manual entry into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1150Electronically import maternal data into patient history2013 FormatWhen electronic access to the mother's data is possible, the system SHALL enable incorporation of selected maternal prenatal and perinatal data into the child's record; such data SHALL be treated as patient history information and designated as maternal.Prenatal ScreeningNormative Statementsno
Req-1149Legal constraints on importing maternal data2013 FormatThe system SHALL follow applicable state or federal privacy laws regarding the importation of maternal information into the child's record.Prenatal ScreeningNormative Statementsno
Req-1153Distinguish maternal from child data2013 FormatWithin the child's record the system SHALL clearly distinguish maternal history data from directly collected child data.Prenatal ScreeningNormative Statementsno
Req-1152Electronically import maternal data from multiple sources2013 FormatWhen the maternal prenatal and perinatal record is split across more than one system (e.g. prenatal care and Labor & Delivery and if electronic access is possible, the system SHOULD enable incorporation of maternal information from each of those systems into the child's record.Prenatal ScreeningNormative Statementsno
Req-1155