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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Information Technology and Quality
Improvement

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What clinical documentation capabilities will I need to implement?

There are two core objectives emphasizing clinical documentation capabilities.  These are:  

1. Vital signs

Core Objective for Eligible Professionals and Eligible Hospitals:  

  • Record and chart changes in vital signs (specifically height, weight, and blood pressure, calculate and display BMI, plot and display growth charts for children 2-20 years, including BMI. 

Measure:

  • For more than 50 percent of all unique patients age 2 and over seen by the eligible professional or admitted to the eligible hospital’s inpatient or emergency department,  height, weight, and blood pressure recorded as structured data.

Exclusion:

  • Any eligible professional who sees only patients 2 years old or younger or who believe that the vital signs have no relevance on their scope of practice.

Your certified EHR should provide you with the ability to enter patients’ height, weight, and blood pressure in a format that can be recognized electronically and correctly categorized.  This allows the EHR to automatically calculate and display BMI.   Additionally, growth charts (including BMI) must be plotted and displayed for patients aged 2-20 years.  Once the patient’s height and weight is entered as structured data, the EHR will plot and electronically display growth charts.

2. Smoking status for patients 13 years old or older  

Core Objective for Eligible Professionals and Eligible Hospitals:  

  • Record smoking status for patients 13 years old or older.

Measure:

  • More than 50 percent of all unique patients 13 years old or older seen by the eligible professional or admitted to the eligible hospital’s inpatient or emergency department have smoking status recorded.  

Exclusion:

  • Any eligible professional who sees no patients 13 years or older during the EHR reporting period.

Your certified EHR will also enable you to electronically record, modify, and retrieve the smoking status of a patient.  All certified EHRs will use the following structured data category types:     

  • Current every day smoker
  • Current some day smoker
  • Former smoker
  • Never smoker
  • Smoker, current status unknown
  • Unknown if ever smoked
Developed by the Health Resources and Services Administration as a resource for health centers and other safety net and ambulatory care providers who are seeking to implement health IT.
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