Critical Elements of Pediatric Documentation

Critical Elements Documentation

of

Pediatric

As pediatric care is different from adult care, pediatric documentation must be made with special attention to specifics. The changing guidelines (for example, fluctuations in the age range for children who should receive influenza vaccinations) make it more challenging. There are some critical elements that you must not overlook when documenting pediatric care. The American Academy of Pediatrics (AAP) insists that pediatric EMRs must facilitate the recording of these elements to become pediatric-competent. Here is a detailed look into each of these elements.

Patient Identification

The ability to capture patient identifiers is critical since many changes may occur in the days and weeks following a child’s birth. Though many EMR systems require the use of a government-issued identification number, newborn infants do not receive that number for a significant period of time after birth. In such cases, you may enter temporary data into the corresponding fields.

The names of the infant may change in the days and weeks following birth. You must record these changes in the electronic medical

records properly.

It

is also

required to maintain a record of multiple names used by a patient.

Time of Birth The time of a child’s birth is very important for calculating the exact age in the first days of life. This information must be entered in your electronic record system accurately.

Growth Data Pediatricians can judge their patients’ health by reviewing body measurements including weight, height, head circumference and body mass index. The ability to calculate, display and compare growth percentiles and body mass index with normal ranges is very significant. Head circumference is a measurement used almost exclusively for pediatric patients. As small changes in these growth parameters are quite important for small children, growth data must be entered in EMR systems.

Immunizations Multiple immunizations for pediatric health maintenance have to be carefully documented. You should record when vaccine information statement (VIS) is given and what version of VIS was given. Since pediatricians require data about immunization completeness in multiple formats, quick availability of immunization reports is also critical.

Medication Dose Enter details of medication dosages in the most accurate manner since small errors can cause serious complications in pediatric patients. Pediatric drug dosages are calculated on the basis of age or body weight. You should enter the correct dosages in your system. A good EMR should have the ability to compute safe and convenient doses for liquid medications; it should also support the incorporation of age-based dosing decision support.

Challenges of Using a Pediatric EMR While documenting a pediatric visit in an electronic medical record, having templates for acute and chronic conditions would really help providers to enhance the efficiency of documentation and adhere to clinical guidelines. Using a pediatric EMR with templates for growth tracking, immunization management, medication dosing and patient identification will streamline your documentation and make it standardized. If it is supported with decision making tools, it can further enhance efficiency and accuracy. However, there are several challenges in implementing such a system such as:



Cost – Buying a specialty EMR poses financial challenges to small practices.

First, they should ensure that the system facilitates the recording of all critical elements efficiently with the vendor. Next, they should train their employees to get familiar with the system.



Limitations to Narrative Description – Though templates save time and improve documentation efficiency, they limit narrative descriptions with rigid choices. Narrative descriptions are vital in complex cases.



Copy-Paste Errors – If the provider is handling a number of cases, they may copy-paste data to save time. Excessive copy-pasting may cause providers to overlook the details of data and the data may be entered in the wrong fields.

However, blending the virtues of EMR and medical transcription can produce complete, accurate and efficient documentation. In EMR transcription, dictations from physicians are transcribed by experienced and skilled transcriptionists. The transcribed data is reviewed by proofreaders and edited by editors, if necessary. The data thus obtained after a thorough analysis is populated into relevant EMR fields by the transcription provider, ensuring accurate and streamlined documentation.

Contact MTS Transcription Services 8596 E. 101st Street, Suite H Tulsa, OK 74133

Main: (800) 670 2809 Fax: (877) 835-5442