There are many choices for Electronic Health Record (EHR) Systems on the market today. An office-based pediatric practice needs a full-featured and easy to use pediatric clinical template system. It is confusing and time-consuming for providers if they have to choose from hundreds of clinical templates with many variations. A great pediatric EHR system should come standard with a simple and easy to use template set that contains all the well visit templates and select sick visit templates. Most pediatric practice owners can use a well thought-out clinical template set with minimal to no changes. If changes are needed, most pediatric practice owners prefer to print out the templates and have a person from the EHR company make the updates so the practice does not need to invest months/years training staff to be super users of an EHR system.
Let’s take a close look at what should be included in the Pediatric Clinical Templates:
1. Common to All Pediatric Clinical Templates: All pediatric clinical templates should display the patient name, age, and vitals saved and provide quick access to the Electronic Prescription module, growth charts, allergies, and scanned documents. Most templates should provide the ability for the providers to easily order vaccinations and procedures for fulfillment by the nurses and/or medical assistants in the office. The design of the templates should reduce the number of items that the provider needs to remember, without providing a complicated interface for the provider to record their clinical note. Some EHR systems look like an excel spreadsheet, rather than a simple user interface. Ideally, the look and feel should be as close to paper charting as possible or designed in a manner that it is easy to use. The clinical template should allow a provider to document the ICD10 code associated with the visit as well as the appropriate level of service.
2. Well Visit Clinical Templates: The well visit templates should include about 18 clinical templates by age. These clinical templates should have the majority of the clinical questions so a pediatric provider can quickly identify/remind themselves of what needs to be completed during the clinical visit and quickly document by clicking on what was done/completed. Also, the provider should be able to add a sick visit into the visit and document as little or as much as needed in a simple and easy to use manner. The areas of the template might include patient history, family history, review of systems, and physical exam. Additionally, the template should have integrated a dental decay template and for the older children, a depression screening tool as well as an assessment/plan section and provide anticipatory guidance that is based on the patient’s age.
3. Sick Visit Clinical Templates: The sick visit templates should include about 14-15 clinical templates by different disease areas or function. The core sick template is usually called something like ‘Standard Sick’ template that can be used in almost all sick visits at the office. Providers find it easier and more effective for the staff/providers to use a specific template in some select disease areas. For example, an asthma template provides specific focus in the area of asthma symptoms such as wheezing, cough, congestion, fever, earache, headache, etc. This information such as checking on ‘wheezing’ then selecting ‘duration in number of days’ and ‘worse with activity’ or ‘during sleep’ should be integrated in a manner that is quickly documented.
With PediatricXpress, we find that many providers see the patients and complete the documentation real time so at the end of the day they are complete with their charting. A pediatric EHR system should be easy to manage and navigate without days or weeks of training. Training and updates should all be included by the pediatric EHR vendor and their trainers should be able to provide tips on how to be more effective and efficient.