Pediatric Emergency Department workflow and documentation: What are the issues? Purpose There has been little research addressing documentation within physician workflow, though this is an area which consumes the majority of physician time with patient care. In addition to the care of a high number of patients with many tasks to be completed, physicians in a Pediatric Emergency Department (ED) setting are interrupted frequently and often juggle multiple tasks. This project was developed to examine electronic documentation within attending physician workflow at a pediatric ED, specifically looking at the factors that shape development and outcomes. Methods This project utilized a mixed-method ethnographic approach involving time-motion data, interruption data, survey data, and provider comments. Participants. Participants were composed of 11 pediatric emergency medicine physicians (7 females, 4 males) at a Level I pediatric ED. The average age of participants was 43.5 years (age range: 33-55 years, SD = 8.00 years). All 11 physicians were attending physicians with a mean experience of 10.2 years (range: 6 months – 23 years, SD = 7.32 years). Procedure. In total, 23 eight-hour shifts were observed. On the day of the observation shift, participants filled out an initial demographics survey and then were instructed to proceed with their normal routine, while the observer shadowed them for the duration of the shift. Data gathered included timestamps of entry/exit of all workrooms and patient rooms, frequency counts of interruptions by source and location, and where documentation occurred. Post-shift survey addressed subjective ratings of busyness of day, amount of documentation left to complete, and satisfaction with documentation. Results Across the 23 observed shifts, a total of 923 interruptions were observed and recorded. Interruptions to documentation were specifically recorded and accounted for 97 (11%) of those interruptions. Results from the post-shift survey revealed that the busier the day, the more documentation the attending physician had left to do at the end of their shift. In addition, the larger the amount of documentation they had left at the end of the day, the less satisfied they were with their documentation. When asked about satisfaction with their current documentation practices (1 = dissatisfied, 5 = satisfied), attending physicians reported a mean satisfaction level of 2.91 (range = 1-5; SD = 1.38), with both a mode and median of 2. There was no significant correlation between experience and satisfaction. Conclusion Electronic documentation in the pediatric ED is shaped by a range of factors. One aspect of documentation that was consistent as an issue was the usability of the EMR, suggesting this played a pivotal role. Recommendations for improvement are included addressing each of the factors observed during this study.