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Req-913Maternal GBS status2013 FormatThe system SHALL record maternal Group B streptococcus (GBS status as Positive, Negative, Unknown, or Pending.Birth InformationNormative Statementsno
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-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-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-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-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-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-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-928Perinatal magnesium sulfate administration2013 FormatThe system SHALL record whether the mother received magnesium sulfate doses prior to or during delivery.Birth InformationNormative Statementsno
Req-929Record tocolytics administration2013 FormatThe system SHALL record whether mother received tocolytics and, if so, which one(sBirth 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-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-932Labor and Delivery2013 FormatThe method and circumstances of labor and delivery are critical to adequate care for a newborn infant.Birth InformationFunctionno
Req-933Labor: spontaneous or induced2013 FormatThe system SHALL record if labor was spontaneous or induced.Birth 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-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-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-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-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-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-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-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-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-943Record umbilical cord blood gas2013 FormatThe system SHALL allow the recording of the umbilical cord blood gas results if available.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-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-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-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-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-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-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-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-964CHIPRA-required quality measures2013 Format
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood...
The system SHALL be able to capture, retrieve, export, and display codified data for CHIPRA-required quality measures for children's health (as they become available AHRQ will specify the minimum data elements necessary.

Examples: childhood immunization status in a clinic over 1 year beginning in January 2011, or weight assessment for children/adolescents over 2 months beginning in March 2011.
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Quality MeasuresNormative Statementsno
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