Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements

Abstract

Clinical documentation has dramatically changed since the implementation and use of electronic health records and electronic provider documentation. The purpose of this report is to review these changes and promote the development of standards and best practices for electronic documentation for pediatric patients. In this report, we evaluate the unique aspects of clinical documentation for pediatric care, including specialized information needs and stakeholders specific to the care of children. Additionally, we explore new models of documentation, such as shared documentation, in which patients may be both authors and consumers, and among care teams while still maintaining the ability to clearly define care and services provided to patients in a given day or encounter. Finally, we describe alternative documentation techniques and newer technologies that could improve provider efficiency and the reuse of clinical data.

The Effect of Electronic Health Record Burden on Pediatricians' Work–Life Balance and Career Satisfaction

“…However, lack of standardized data requests and forms and the need to enter these data in an EHR can be time-consuming and burdensome and result in duplicate documentation. Creation of essential clinical documentation components 34 and including ideal and accessible pediatric EHR functions 35 might reduce burden on pediatricians.…”

“…36 A recent AAP policy statement highlighted the different electronic documentation needs for pediatricians and a lack of best practices in pediatric populations. 35 It points out that "[m]ultiple stakeholders with differing priorities […] have contributed to increased documentation burden and physician burnout." It also discusses several tools to reduce provider documentation burden, including speech recognition software, scribes, and new technologies.…”

Post Severe Acute Respiratory Syndrome Coronavirus 2 Infection Tremors in a Nonverbal Autistic Adolescent

“…SARS-CoV-2 infection in children aged 0-17 years has been increasing as older adults become vaccinated [ 7 ]. COVID-19 vaccines are approved for emergency use in children older than 12 years and for younger children forthcoming [ 8 ].…”

Evaluation of an Electronic Medical Record Module for Nursing Documentation in Paediatric Palliative Care: Involvement of Nurses with a Think-Aloud Approach

“…The complex care and treatment of patients in PPC is reflected in high demands for documentation [ 12 ]. In particular, electronic medical records (EMRs) play an increasingly important role in PPC for documenting complex processes [ 11 , 12 , 13 ]. These records can facilitate communication among multiple professions [ 14 ] and support care coordination and planning [ 11 ].…”