When encountering a pediatric patient in the emergency department (ED) who requires a diagnostic or therapeutic procedure, the medical provider must be able to accurately document the procedure. Clinical documentation has at least four purposes: recording of medical care and subsequent communication among providers, payment for services rendered, medicolegal concerns, and surveillance for public health or research purposes (1,2,3,4,5). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement for the ED record at a minimum prescribes that a report of any procedure, including tests sent and results received, be documented appropriately on the ED chart.

In our high-technology era, medical informatics, including the use of electronic documentation of emergency department care, has become an active issue for many departments. It offers tremendous potential for improved patient care by enhancing patient care continuity, patient safety, and health care system efficiency; advancing research efforts; and supporting surveillance efforts. However, implementing a system of electronic documentation given the realities of limited standards and evolving technology is a major challenge (5,6). To provide additional information to assist with emergency department documentation guidelines, the Centers for Disease Control and Prevention developed Data Elements for Emergency Department Systems (DEEDS) (7). Lastly, an important medicolegal component of medical care is informed consent and the documentation of this process. Issues regarding informed consent are discussed in Chapter 9. Discussion of this topic here will focus on the recording of medical care and medicolegal issues. The topic will be elaborated by reviewing the appropriate documentation of surgical procedures, such as laceration repair (Fig. 11.1); of medical procedures, such as lumbar puncture (Fig. 11.2) and thoracentesis; and of the use of restraints for specific behavioral health issues (Fig. 11.3). Specific information regarding restraint techniques is included in Chapter 3.

Briefly, informed consent in the pediatric patient raises some issues that do not apply to the competent adult patient. The law views the pediatric patient as incompetent to consent to treatment or procedures and is clear in providing that legal right to natural parents or legal guardians on behalf of the child. Although the competent adult patient has the legal and moral right to refuse consent to a procedure or treatment, parents are not given the absolute right to refuse treatment or to have a procedure performed on behalf of their child under the conditions of an emergency (8).

An emergency has been defined as “any condition that requires prompt medical intervention” but is not restricted to conditions that may cause death or disability. If the life or health of the child would be adversely affected by a delay caused by the parents’ refusal, the situation is deemed an emergency (8). Limitations on parental authority have been supported by the Committee on Bioethics of the American Academy of Pediatrics and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. More detailed discussion of informed consent and refusal may be found in Chapter 9.