Pediatric Documentation Templates
Pediatric Asthma Template
Executive Summary
The
Partners Pediatric Asthma Template was designed to aid in the documentation of asthma
symptoms as well as to improve adherence to recommendations for assessing
asthmatic patients.
This web site contains views of each section of the
template.
On
the Partners HealthCare System, this template exists within the notes section
of the electronic medical record (EMR).
In its current form, it is meant to assist the provider during a visit
in which a child’s asthma symptoms and medications are reviewed. The interval history and assessment/plan sections
are specific for asthma. However, note
that the chief complaint, history of present illness, social history, neonatal
history, review of systems, physical examination, and laboratory/x-ray findings
sections are reasonably general and could also be used as the basis for
creating a general visit template if desired.
Note
that only relevant sections of the template need to be accessed for a given
visit. For example, if a neonatal
history is not obtained during the visit, there is no need to access this
section.
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; Stephen Morgan, MD; Eric Poon, MD, MPH; James Perrin, MD;
Shelly Bernstein, MD; Peter Greenspan, MD; John Co, MD, MPH; Mark Mandell, MD.
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.