1. Documentation of Developmental History in EMR
Lori L. Fox, BSN, RN
Clinical Documentation Specialist

2. 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

3. 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

4. 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

5. Changes to Developmental History to Document More Specific Developmental Status in the EMR
These options are multi-select
These options are multi-select

6. Changes to Developmental History to Document More Specific Developmental Status in the EMR
QUESTIONS?