EMR Features for Child Patients

Over the past several years, PatientTrac has had many new client enrollments from psychiatrists whose focus is Child and Adolescent Psychiatry. The child psychiatrists presented unique clinical documentation requirements which were not present in PatientTrac or any other electronic medical records application on the market. In early 2011, a select team of these clients worked together using clinical documentation recommendations of the AACAP (American Academy of Child and Adolescent Psychiatry) and presented their specific needs to PatientTrac. PatientTrac has created specific clinical documentation elements for the adequate documentation of child and adolescent patient care, as well as the tools for each user to customize their specific requirements in the clinical components.

All evaluation and progress notes include a number of intake components with specialized elements for each age group.

Child Psychiatric Review of Systems

The PatientTrac Child Psychiatric Review of Systems (HPI, or History of Present Illness) is defaulted to when opening a chart for a patient whose age is equal to 17 years or less. The Child Psychiatric review of systems has specific data elements for:

ADHDAgitation AnxietyAppetiteAutism
BehaviorBody ImageCommunicationConduct DisorderDelusions
EducationEnergyFearsGeneralized AnxietyHallucinations
InterpersonalMoodObsessive
Behavior
Oppositional Defiant DisorderPhysical Symptoms
Self-HelpSensorySeparation
Anxiety
SleepSocial Skills
Speech and LanguageStereotyped
Patterns
StressorsSuicideThought Content
Thought ProcessTicsTrauma

Each of the specific data elements has logic-based sub-elements, allowing clinical documentation on the macro or micro level, depending on the user’s request. For example, in documenting ADHD the clinical elements include sub-elements for symptoms, duration, severity and place, and subjective comments for Inattention, Hyperactivity and Impulsivity. The end user can document clinical information with the following complexity levels:

  1. simply normal for ADHD
  2. presents with ADHD symptoms, in partial remission or full remission
  3. comprehensive level of documentation regarding the ADHD review

 

Examples of each complexity level are below:

  1. She denies history of symptoms consistent with ADHD.
  2. She reports issues with attention, hyperactivity and impulsivity.
  3. ADHD: INATTENTION: Diana verbalized symptoms of: makes careless mistakes, difficulty sustaining attention in task, difficulty listening when spoken directly. Her frequency is reported as often and symptoms are reported to occur at home and at school.
    HYPERACTIVITY: states symptoms of squirms in seat, duration was reported as for last couple of years. Her frequency is reported as sometimes and are reported to occur at school.
    IMPULSIVITY: Diana express symptoms of: tends to answers questions before they are finished, duration was reported as for last couple of years, difficulty waiting for turns, duration was reported as for last couple of years. Her frequency is reported as occasionally and symptoms are reported to occur at home and at school. It seems she continues to have issue with: blurts out answers before questions have been completed and difficulty waiting for turns.

 

Child Vital Signs

This component documents a child patient’s height, weight, BP, and other relevant vital signs. Upon entry of data, PatientTrac calculates BMI, BSA, Pediatric Growth Chart, and other desired elements.

Child Developmental History Evaluation

PatientTrac offers both simple and complete Child Developmental History Evaluation. Our Developmental History component includes the ability to document a complete social history pre- and post-birth, health information for mother and child pre- and post-birth, living arrangements, including pertinent challenges within the living environment, and abuse-related issues.

E-Prescribe and Medications

The E-Prescribe and Medications component offers customized print prescriptions, history of previous psychotropic medications, and active medications with updates from the FDA database. Our medication component includes information and consent forms with electronic signature capabilities for patient and provider.

Assessment and Diagnosis

PatientTrac includes the DSM-IV and ICD-9 dictionary, which can be searched by description, code or chapter for AXIS I, AXIS II and AXIS III data entry. PatientTrac tracks the highest 12 month GAF for automatic entry of the highest GAF scale for each subsequent visit.

Laboratory and Orders

Our Orders component has capabilities for both printing orders and electronic submission of lab or radiology testing, complete with the appropriate CPT code and diagnosis to support the test.

Customization and Reliability

PatientTrac progress notes are completely customizable, with different intake elements assigned to different note types. More about customization of the progress notes here.

As with all PatientTrac elements, clinical data is maintained in the PatientTrac Clinical Repository database and is projected on the progress notes in a narrative manner for ease of comprehension.

PatientTrac provides patient education handouts, inform and consent forms, and patient contracts within the software application. We have excellent user tools to create and manage patient education materials. During the visit, a provider can easily print educational handouts for patients, parents and caretakers.

WE ARE DEDICATED TO PROVIDING YOU WITH THE BEST EMR TO HELP YOU TAKE THE BEST CARE OF YOUR PATIENTS!