In a recent article published in Hospital Pediatrics(10.1542/hpeds.2020-0080) titled “Complexity of Documentation Needs for Children with Medical Complexity:
Implications for Hospital Providers,” authors seek to understand how providers create
and use clinical notes to support the care of children with medical complexity (CMC).
It is a challenging and worthwhile undertaking as a growing number of hospitals are
establishing programs to improve care coordination for CMC.
While we already know that providers spend a lot of time documenting within the electronic
health record (EHR), how this documentation can be optimized to facilitate care coordination
for CMC remains elusive. As a first step toward answering this question, authors begin
by describing clinical notes generated by one hospital-based pediatric complex care
program in the Midwest, which serves as a medical home for CMC in the area.
In this exploratory study, authors employed both field observations of office visits
and focus groups with program staff to identify the types and purpose of clinical
notes created and utilized within the EHR. Authors elicited at least seven unique
note types generated by staff in different contexts and intended for a variety of
audiences and purposes. Four themes characterized the diversity of note types and
functions, sources of information used to create and update notes, roles of note authors,
and motivations for note creation. Results include rich quotes provided by focus group
participants, such as describing the summary note as “the breakdown” to be given to
new providers. Another quote describes how staff might attend subspecialty clinic
visits with families and act as “an additional set of ears and support to review things
after the visit.” These quotes illustrate the important role that notes and program
staff serve in the communication of health information across providers and care settings
for CMC.
The study’s findings further underscore the unique demands of coordinating care for
CMC, as well as the need to streamline clinical documentation to support information
sharing amongst not only healthcare professionals but families. Overall, results prompt
the reader to consider how we optimize documentation to support care coordination
for CMC. Authors suggest that the answer to this question is, like the children they
care for, complex.
Copyright © 2020 American Academy of Pediatrics
