Enhancing Developmental History Documentation in EMR
Explore the evolution of documenting developmental history in Electronic Medical Records (EMR) to capture specific details like global delays, speech delay, and intellectual disability degree with descriptors. The advancements include options for ages under and over three, multi-select choices, and improved specificity for patient admission status.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
Documentation of Developmental History in Documentation of Developmental History in EMR EMR Lori L. Fox, BSN, RN Clinical Documentation Specialist 1
Documentation of Developmental History Documentation of Developmental History How many of you see this in documentation? Global Developmental Delay Speech Delay 12 yo with Delayed milestones (Pt says a few words and uses an Ipad for communication, She is ambulatory. Has bilateral hearing aides but does not like to wear them.) 3 yo with Delayed milestones ( Vocal, Uses a Walker- has PT and Speech) 9 yo with Delayed milestones (global delays, pt is non- ambulatory and non-verbal) Learning Support at school, IEP, ST/OT, does not like loud noises 2
Moving Toward Developmental Specificity in the EMR Moving Toward Developmental Specificity in the EMR Met with Epic Analyst to see what could be built in EMR Provided Specialist with selections based on age Analyst able to build options in the Inpatient H&P Template Built with options of 3 years and under and 3 years and over 3
Changes to Developmental History to Document More Specific Changes to Developmental History to Document More Specific Developmental Status in the EMR Developmental Status in the EMR In an attempt to capture specificity of the developmental status of patients on admission, the developmental history section has been expanded. It now includes the specific types of delays including descriptions of the delay: Delayed milestones for 3 years old and younger Fine and or Gross Motor delay Expressive and Receptive Language delay For children over 3 years old, it includes the degree of Intellectual Disability with descriptors to help you determine the degree of disability
Changes to Developmental History to Document More Specific Changes to Developmental History to Document More Specific Developmental Status in the EMR Developmental Status in the EMR These These options are options are multi multi- -select select These options These options are multi are multi- -select select
Changes to Developmental History to Document More Specific Changes to Developmental History to Document More Specific Developmental Status in the EMR Developmental Status in the EMR QUESTIONS? 6
