Enhancing Developmental History Documentation in EMR
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Documentation of Developmental History in
EMR
Lori L. Fox, BSN, RN
Clinical Documentation Specialist
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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
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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
Changes to Developmental History to Document More Specific
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
Developmental Status in the EMR
These options
are multi-select
These
options are
multi-select
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Changes to Developmental History to Document More Specific
Developmental Status in the EMR
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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.
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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
