Pediatric Documentation Templates
When documenting a visit in an electronic health record (EHR), having templates for acute and chronic conditions can assist providers by increasing the efficiency with which a visit is documented and enhancing adherence to clinical guidelines for those conditions. While some vendors provide templates that can be modified to suit a particular practice, most need to be created de novo. This process can be time consuming and costly to conduct, particularly for small group practices or solo practitioners.
Under the Agency for Healthcare Research and Quality (AHRQ) funded grant Improving Pediatric Safety and Quality with Healthcare IT, the Partners Quality Improvement Group created pediatric visit templates for the ambulatory environment. These templates were designed to enhance care both at health maintenance visits as well as for children with chronic conditions. This work was done in collaboration with Partners Pediatrics Quality Improvement (PPQI) and Partners Information Systems (IS) in Boston, MA. These pediatric templates are currently in use in the Partner's EHR, known as the Longitudinal Medical Record (LMR).
The templates are based on national guidelines and may be modified to suit a particular clinical practice's needs. They are being shared with the health IT community in order to provide clinicians with an example set of templates that can be replicated in other EHR systems. The aim is that these templates will ease the implementation process for others by providing a guide, leading the health IT community to wider adoption of templates to help improve compliance with clinical guidelines and clinical documentation efficiency within a practice environment.
These tools were created using national, state and local guidelines, and group consensus regarding best practices. These guidelines and their interpretation by clinicians at Partners Healthcare System may not represent the standard of care across all regions or settings, and are not intended to be adopted or applied without independent assessment as to their application in the setting in question. Moreover, guidelines change over time (for example, the age range for children who should receive influenza vaccinations was recently extended to 59 months), and thus any rules and/or reminders part of these templates may necessitate the addition or modification of certain items to ensure that they remain consistent with current guidelines. Accordingly, the tools included here are intended only as examples or guides for the development of similar templates in other settings. Partners Healthcare System and its affiliates disclaim any and all responsibility or liability associated with the use of the templates displayed here by third parties.