Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements.

Abstract

Clinical documentation is a fundamental component of the practice of medicine. It has significantly evolved over the past decade, largely because of the growth of health information technology and electronic health records. Although government agencies and other professional organizations have published position statements on the structure and use of electronic documentation, few have specifically addressed the documentation needs for the care of children. A policy statement on electronic documentation of clinical care by general pediatric and subspecialist providers by the American Academy of Pediatrics is needed. This statement provides insight on the unmet needs of key stakeholders to direct future research and development of the electronic media necessary to enhance the wellness of children and improve health care delivery. It also addresses the challenges and opportunities for efficient and effective clinical documentation in pediatrics.