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.