It is very important to ensure that all crucial elements are included in pediatric documentation, as it deals with the conditions of infants and children.

1. Critical Elements of Pediatric
Documentation
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.

2. 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.

3. 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.

4. 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