Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements

Authors:
  • CTCOUNCIL ON CLINICAL INFORMATION TECHNOLOGY
    COUNCIL ON CLINICAL INFORMATION TECHNOLOGY
  • EWEmily Chui Webber
    Emily Chui Webber
  • GAGregg M. Alexander
    Gregg M. Alexander
  • SCSandy Lee Chung
    Sandy Lee Chung
  • AHAlexander M. Hamling
    Alexander M. Hamling
  • EKEric S. Kirkendall
    Eric S. Kirkendall
  • AMAnn M. Mann
    Ann M. Mann
  • RSReza Sadeghian
    Reza Sadeghian
  • ESEric Shelov
    Eric Shelov
  • AWAndrew M. Wiesenthal
    Andrew M. Wiesenthal
Publisher website
Google Scholar
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.

This publication has 46 references indexed in Scilit: