Pediatric Documentation Templates

Acute Respiratory Infection (ARI) Smart Form

Executive Summary

The Partners Pediatric Acute Respiratory Infection (ARI) smart form is a guideline-driven template designed to streamline urgent care visits for patients ages 6 months to 18 years presenting with ARIs. The form is designed to assist with the assessment and management of non-specific upper respiratory infections, otitis media, pharyngitis, strep pharyngitis, influenza, cough, pneumonia, and sinusitis. The form provides check boxes for symptoms and physical examination specifically related to ARIs; therefore, it does not provide the opportunity to document other problems.

After the provider specifies a primary and possibly a secondary diagnosis, it provides guideline-based options for management. After the provider selects the desired items for the management plan, the system then generates prescriptions, handouts, and a completed note. This web site includes views of each page of the ARI smart form, as well as a preview of the note.

Source

This template was developed under a grant from the Agency for Healthcare Research and Quality (AHRQ), Improving Pediatric Safety and Quality with Healthcare IT, in collaboration with the Partners HealthCare System Quality Improvement Group, the Massachusetts General Hospital for Children, and Partners HealthCare System Inc. Information Systems.  Listed below are the names of clinicians and experts who contributed to development of the template.  In addition, the LMR Pediatric Content Subcommittee and the main LMR Content Committee reviewed the template, and approved it for use with the Partners Longitudinal Medical Record (LMR).

Contributors

Timothy Ferris, MD, MPH; Fabienne Bourgeois, MD, MPH; James Perrin, MD; John Co, MD, MPH; Maya Olsha-Yehiav; Matvey B. Palchuk, MD, MS; Frank Y. Chang; David P. Taylor, MS; Jeffrey L. Schnipper, MD, MPH; Jeffrey Linder, MD, MPH; Qi Li, MD, MBA; Blackford Middleton, MD, MPH, MSc.

Template

Disclaimer

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 of their suitability for a particular setting. Moreover, guidelines change over time (for example, the age range for children who should receive influenza vaccinations was recently extended to 59 months). The rules and/or reminders contained within these templates may need the addition or modification of certain items to ensure that they remain consistent with current guidelines. Therefore, 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.