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Allergies

Allergies. [Allergies] could include items such as foods or environmental agents. Closest conformance criterion: DC.1.3.2 #1 (The system SHALL capture true allergy, intolerance, and adverse reaction to drug, dietary or environmental triggers as unique, discrete entries.).

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Allergies

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  1. Allergies • [Allergies] could include items such as foods or environmental agents. • Closest conformance criterion: DC.1.3.2 #1 (The system SHALL capture true allergy, intolerance, and adverse reaction to drug, dietary or environmental triggers as unique, discrete entries.). • INCLUDED, noncontroversial • Reference number: 5

  2. Allergies • Allow the classification of reactions into allergic reactions, side effects, and intolerances • Closest conformance criterion: DC.1.3.2 #1 (The system SHALL capture true allergy, intolerance, and adverse reaction to drug, dietary or environmental triggers as unique, discrete entries.). • INCLUDED, noncontroversial • Reference number: 6

  3. Allergies • The user determines what defines an allergy or adverse reaction • Closest conformance criterion: DC.1.3.2 #4 (The system SHOULD provide the ability to capture the reaction type). • INCLUDED, noncontroversial • Reference number: 8

  4. Archiving • Store data until the statutorily designated time • Closest conformance criterion: I.1.2.1 #1 (The system SHALL provide for the storage and retrieval of health record data and clinical documents for legally proscribed (sic) time. ). • INCLUDED, noncontroversial • Reference number: 9

  5. Communications • The user may indicate who they are sending results to and the system will track this • Closest conformance criterion: DC.1.10.1 #8 (The system MAY route results to patients by methods such as phone, fax, electronically or in the form of a letter). • INCLUDED, noncontroversial • Reference number: 10

  6. Consent • In cases where advanced directives are managed by the system, provide forms appropriate to both patients and guardians where the patient is below the legal age of consent • Closest conformance criterion: DC.1.11.2 (The system MAY be able to indicate that the patient’s personal representative (guardian/surrogate) has completed advanced directive(s) on their behalf. ). • INCLUDED, noncontroversial • Reference number: 12

  7. Consent • Allow recording of both consent and assent to treatment • Closest conformance criterion: DC.1.11.3 #7 (EHR systems SHOULD allow documentation of an assent as appropriate for patients legally unable to consent. ). • INCLUDED, noncontroversial • Reference number: 11

  8. Decision Support • Incorporate age, weight, and disease criteria into alerts related to laboratory results • Closest conformance criterion: DC.1.10.1 #11 (The system MAY trigger decision support algorithms from [test] results. ). • INCLUDED, noncontroversial • Reference number: 31

  9. Decision Support • Integrate patient and family preferences into clinical decision support • Closest conformance criterion: DC.1.11.1 #3 (The system SHOULD integrate patient and family preferedecision support systems). • INCLUDED, noncontroversial • Reference number: 34

  10. Decision Support • Link care processes to the problem list • Closest conformance criterion: DC.1.5 #9 (The system MAY associate encounters, orders, medications, notes with one or more problems.). • INCLUDED, noncontroversial • Reference number: 35

  11. Decision Support • Link lab values to problem list • Closest conformance criterion: DC.1.5 #9 (The system MAY associate encounters, orders, medications, notes with one or more problems.). • INCLUDED, noncontroversial • Reference number: 37

  12. Decision Support • Link medical imaging to items all on the problem list • Closest conformance criterion: DC.1.5 #9 (The system MAY associate encounters, orders, medications, notes with one or more problems.). • INCLUDED, noncontroversial • Reference number: 38

  13. Decision Support • Link orders to problems [in problem lists] • Closest conformance criterion: DC.1.5 #9 (The system MAY associate encounters, orders, medications, notes with one or more problems.). • INCLUDED, noncontroversial • Reference number: 39

  14. Decision Support • Provide problem lists link to medical orders, lab, medical imaging, disease specific guidelines, or care processes including rationale for care. • Closest conformance criterion: DC.1.5 #9 (The system MAY associate encounters, orders, medications, notes with one or more problems.). • INCLUDED, noncontroversial • Reference number: 43

  15. Decision Support • Provide decision support for special immunizations such as palivizumab • Closest conformance criterion: DC.1.6.1 #1 (The system SHALL support presentation of guidelines and protocols to clinicians). • INCLUDED, noncontroversial • Reference number: 42

  16. Decision Support • Link disease specific guidelines to the problem list • Closest conformance criterion: DC.1.6.1 #4 (The system SHALL present guidelines and protocols appropriate for the patient’s problem list. ). • INCLUDED, noncontroversial • Reference number: 36

  17. Decision Support • Indicate the source of any applicable guidelines or decision support rules • Closest conformance criterion: DC.1.6.2 #4 (The system SHOULD allow tracking of updates to care plans by: authors, creation date, version history, references, local sources, non-local sources). • INCLUDED, noncontroversial • Reference number: 33

  18. Decision Support • Allow for disease specific health maintenance schedules with accompanying decision support • Closest conformance criterion: DC.2.1.1 #2 (The system SHALL enable access to standards and practices related to age, gender, normal growth and development and medical conditions [this assumes that "assessments" refers to forms for data collection]). • INCLUDED, noncontroversial • Reference number: 23

  19. Decision Support • In cases where forms vary with age, select forms to be presented based on age. • Closest conformance criterion: DC.2.1.1 #2 (The system SHALL enable access to standards and practices related to age, gender, normal growth and development and medical conditions [this assumes that "assessments" refers to forms for data collection]). • INCLUDED, noncontroversial • Reference number: 29

  20. Decision Support • Modify displays based on age • Closest conformance criterion: DC.2.1.1 #2 (The system SHALL enable access to standards and practices related to age, gender, normal growth and development and medical conditions [this assumes that "assessments" refers to forms for data collection]). • INCLUDED, noncontroversial • Reference number: 40

  21. Decision Support • Modify displays based on gestational age at birth • Closest conformance criterion: DC.2.1.1 #2 (The system SHALL enable access to standards and practices related to age, gender, normal growth and development and medical conditions [this assumes that "assessments" refers to forms for data collection] [assumes gestational age could be treated as a "medical condition," which is reasonable]). • INCLUDED, noncontroversial • Reference number: 41

  22. Decision Support • Remind users of anticipatory guidance topics based on age • Closest conformance criterion: DC.2.2.1.2 #1 (assuming that "anticipatory guidance topics" can be considered a "care plan") (The system SHALL support access to resources for care plans that are context sensitive to patient specific data and assessment, and are appropriate to the age, gender, developmental stage and medical condition of the patient (DC 1.3.1, DC 1.4, DC 1.5, DC 1.6)). • INCLUDED, noncontroversial • Reference number: 44

  23. Decision Support • Remind users of anticipatory guidance topics based on risk factors • Closest conformance criterion: DC.2.2.1.2 #1 (assuming that "anticipatory guidance topics" can be considered a "care plan") (The system SHALL support access to resources for care plans that are context sensitive to patient specific data and assessment, and are appropriate to the age, gender, developmental stage and medical condition of the patient (DC 1.3.1, DC 1.4, DC 1.5, DC 1.6)). • INCLUDED, noncontroversial • Reference number: 45

  24. Decision Support • Remind users of anticipatory guidance topics based on topics previously discussed • Closest conformance criterion: DC.2.5.1 (sort of) (The system SHOULD present alerts for all patient specific preventive services to the provider (is anticipatory guidance a preventive service?)). • INCLUDED, noncontroversial • Reference number: 46

  25. Decision Support • Alert clinicians to the need for developmental screening based on guidelines • Closest conformance criterion: DC.2.5.1 #1 (The system SHOULD identify services for preventive care and wellness from patient demographics (eg. age, sex, region) ). • INCLUDED, noncontroversial • Reference number: 21

  26. Decision Support • Alert clinicians to the need for hearing and vision screening per guidelines • Closest conformance criterion: DC.2.5.1 #1 (The system SHOULD identify services for preventive care and wellness from patient demographics (eg. age, sex, region) ). • INCLUDED, noncontroversial • Reference number: 22

  27. E-Prescribing & Ordering • Allow export of data to national drug databases designed to detect adverse drug events • Closest conformance criterion: COVERED IN "REGISTRIES PACKAGE" ((DC.1.3.3 Manage immunizations; S.1.1 Registry notification; S.3.1.2 Encounter-specific functionality; S.3.3.6 Health service reports at the conclusion of an episode of care; I.1.3.1 Unique identity, registry, and directory services; I.3.2 Distributed registry access; I.5.4 Interchange agreements; I.6 Business rules management)). • INCLUDED, noncontroversial • Reference number: 49

  28. E-Prescribing & Ordering • Handle immunization separately from other medications • Closest conformance criterion: DC.1.3.3 ([Manage immunizations]). • INCLUDED, noncontroversial • Reference number: 56

  29. E-Prescribing & Ordering • Link adverse drug reactions, including allergies, to the activity of ordering or modifying a prescription • Closest conformance criterion: DC.1.8.1 #15 (The system SHOULD check and report allergies, drug-drug interactions, and other potential adverse reactions, when new medications are ordered. ). • INCLUDED, noncontroversial • Reference number: 60

  30. E-Prescribing & Ordering • Allow recording of over-the-counter medications, herbal remedies, and vitamin preparations in the medication list • Closest conformance criterion: DC.1.8.3 (The system SHALL provide a user interface to enter non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements. ). • INCLUDED, noncontroversial • Reference number: 52

  31. E-Prescribing & Ordering • When a medication is discontinued, the user would have the ability to indicate if a medication was ineffective. • Closest conformance criterion: DC.2.3.1.1 #8 (The system SHOULD allow checking of medications against a list of drugs noted to be ineffective for the patient in the past. ). • INCLUDED, noncontroversial • Reference number: 67

  32. E-Prescribing & Ordering • Indicate when dosing decision support is based on evidence • Closest conformance criterion: DC.2.7.1 #1 (Upon request, the system SHALL provide appropriate evidence-based documentation for clinical care recommendations. ). • INCLUDED, noncontroversial • Reference number: 59

  33. Education • Provide patient education materials that are appropriate for patients in varying age ranges • Closest conformance criterion: DC.3.2.4 #9 (The system MAY enable age-appropriate and/or reading-ability appropriate educational materials for the patient and/or patient representative ). • INCLUDED, noncontroversial • Reference number: 69

  34. Epidemiology • Facilitate epidemiologic studies by recording living situation • Closest conformance criterion: S.1.4.3 #1 & #2 (The system SHOULD provide a mechanism to identify the patient’s primary residence. The system MAY provide a mechanism to identify the patient’s secondary or alternate residence. ). • INCLUDED, noncontroversial • Reference number: 71

  35. Family Linkage • Allow linkages between siblings charts • Closest conformance criterion: S.3.5.1 #1 (The system MAY support the identification of persons related by genealogy.). • INCLUDED, noncontroversial • Reference number: 74

  36. Family Linkage • Allow linkages between the charts of parents and children • Closest conformance criterion: S.3.5.1 #1 (The system MAY support the identification of persons related by genealogy.). • INCLUDED, noncontroversial • Reference number: 75

  37. Family Linkage • Allow the creation of family groups of records within the system, for the purpose of moving between records within a family, subject to patient preferences, family preferences, and privacy regulations • Closest conformance criterion: S.3.5.1 #1 (The system MAY support the identification of persons related by genealogy.). • INCLUDED, noncontroversial • Reference number: 76

  38. Family Linkage • Link records in cases where there is a medical reason to do so, such as in cases of familial disease • Closest conformance criterion: S.3.5.1 #1 (The system MAY support the identification of persons related by genealogy.). • INCLUDED, noncontroversial • Reference number: 79

  39. Guardianship • Allow recording of a guarantor, who may be different from the parent or guardian • Closest conformance criterion: S.3.5.2 #1 (The system MAY support the identification of persons related by insurance plan. ). • INCLUDED, noncontroversial • Reference number: 89

  40. Immunizations • Allow recording of immunizations including lot numbers and vaccine information statements • Closest conformance criterion: DC.1.3.3 #1 & #2 (The system SHALL record as discrete data elements data associated with any immunization given including date, type, lot number and manufacturer. The system SHOULD allow the association of standard codes with discrete data elements associated with an immunization.). • INCLUDED, noncontroversial • Reference number: 93

  41. Immunizations • Based on known immunization data, calculate immunization status (current versus delayed) and display in summary lists • Closest conformance criterion: DC.1.3.3 #3 (The system SHALL determine any required immunizations during an encounter based on a current accepted schedule such as that from the Centers for Disease Control and Prevention. ). • INCLUDED, noncontroversial • Reference number: 97

  42. Immunizations • Provide alerting and reminders for missedimmunizations • Closest conformance criterion: DC.1.3.3 #3 (The system SHALL determine any required immunizations during an encounter based on a current accepted schedule such as that from the Centers for Disease Control and Prevention.). • INCLUDED, noncontroversial • Reference number: 101

  43. Immunizations • Include mechanisms for immunization decision support that includes easy updating as recommendation change is included. • Closest conformance criterion: DC.1.3.3 #5 (The system SHALL allow for the updating of the immunization schedule). • INCLUDED, noncontroversial • Reference number: 100

  44. Immunizations • Allow flexible reporting of immunizations in a given practice to support required vaccine program reporting • Closest conformance criterion: DC.1.3.3 #8 (The system SHOULD prepare a report of a patient's immunization history upon request for appropriate authorities such as schools or day-care centers. ). • INCLUDED, noncontroversial • Reference number: 92

  45. Lab Results • In the case of laboratories, allow recording of verification and communication to family members • Closest conformance criterion: DC.3.2.3 #1, 3, 4 (The system SHALL facilitate documentation of communications between providers and patients or their representatives. The system SHALL capture details of provider communications with patients or family (e.g. date, provider id, details of communication, result of communication requests). The system SHALL document communication originating with the patient or patient representative (e.g. date, entity, details of communication)). • INCLUDED, noncontroversial • Reference number: 103

  46. Miscellaneous • Links to a source where living wills are stored • Closest conformance criterion: DC.1.11.2 #2 (The system SHOULD be able to indicate the type of advanced directives such as living will, durable power of attorney, or a "Do Not Resuscitate order".). • INCLUDED, noncontroversial • Reference number: 110

  47. Miscellaneous • Coordinate bed identification between facilities, for transport from general hospital to children's hospital or to NICU. • Closest conformance criterion: S.1.4.2 #1 (The system SHOULD identify and display/view the patient’s assigned location, unambiguously. ). • INCLUDED, noncontroversial • Reference number: 109

  48. Parental Data Entry • Incorporate documentation from external sources • Closest conformance criterion: DC.1.1.3 #1, and DC.3.2.3 #4 (The system SHALL allow external documents to be stored in the system, and The system SHALL document communication originating with the patient or patient representative (e.g. date, entity, details of communication) ). • INCLUDED, noncontroversial • Reference number: 119

  49. Parental Data Entry • Distinguish data provided by the clinician from data provided by the parent, guardian, teacher, translator, or family • Closest conformance criterion: DC.1.1.4 #3 & #4 (The system SHALL capture, explicitly label the source of clinical data provided on behalf of the patient. The system SHALL present patient-originated data for use by care providers.). • INCLUDED, noncontroversial • Reference number: 118

  50. Patient Identification • Allow the assignment of temporary identifiers in cases where a government issued identifier is not available. • Closest conformance criterion: DC.1.1.1 #2 (The system SHALL provide the ability to uniquely identify a patient and tie the record to a single patient. ). • INCLUDED, noncontroversial • Reference number: 129

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