Department of Pediatrics, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York;
Pediatric Physicians' Organization at Children's Hospital, Boston Children's Hospital, Brookline, Massachusetts; and.
Pediatrics. 2020 Jul;146(1). doi: 10.1542/peds.2020-1682. Epub 2020 Jun 29.
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.
临床文档是医学实践的基本组成部分。在过去的十年中，它发生了重大演变，主要是由于健康信息技术和电子健康记录的发展。尽管政府机构和其他专业组织已经发布了关于电子文档结构和使用的立场声明，但很少有专门针对儿童护理文档需求的声明。儿科学会需要发布一份关于普通儿科医生和专科医生提供的临床护理电子文档的政策声明。该声明深入了解了主要利益相关者未满足的需求，以指导未来研究和开发必要的电子媒体，从而增强儿童的健康，并改善医疗服务的提供。它还解决了儿科领域高效和有效的临床文档记录面临的挑战和机遇。
