Pediatric Records
With the exception of intensivists treating neonates, the care of children is a legally low-risk endeavor. General pediatricians tend to get in trouble more for what they do not do than for what they do. This is to be expected in any area of medicine in which the vast majority of patient encounters are either preventive in nature or are for minor illnesses. Many of the cases in which pediatricians are charged with failure to diagnose a condition actually involve a systems failure in the physician’s office routine rather than an error in medical judgment. As with all other physicians who have highly routinized practices, pediatricians must take special care to document all findings and ensure that atypical events are identified.
Pediatric recordkeeping has two complicating aspects. First, most visits are for minor illnesses. Second, the records must track growth and development, which is not an issue in adult medical practice. The difficulty with a practice that is overwhelmingly devoted to minor illnesses and well-child care is that it is easy to miss subtle developmental problems and rare, fast-evolving illnesses such as meningitis. This is particularly a problem in children with atypical presentations. It can be impossible to tell the early onset of meningitis from an upper respiratory infection. If the disease progresses very quickly, the child may be permanently injured before the physician could reasonably have expected to make the proper diagnosis.
Pediatric practice is telephone intensive. This is consistent with the minor nature of most pediatric illnesses. Most calls to the pediatrician are for reassurance that the child is not seriously ill. More problematically, most calls are handled by office personnel other than the physician in charge. These calls are seldom recorded in the patient’s chart, and calls are often answered without reference to the chart. This leads to the most common telephone- related legal problem: misunderstanding about the severity or progression of the child’s illness.
One of the most important diagnostic indicators for children is the parent’s level of concern. If a parent calls the physician’s office repeatedly over a period of hours or days, this should alert the physician that the child should be seen immediately. Legally, it is very difficult to defend cases in which the parents have repeatedly called the physician’s office. If the child is injured due to a missed diagnosis or treatment failure, the jury will assume that the problem could have been managed if the child had been seen.
Physicians must know what their office personnel tell patients who call with medical questions. There must also be a protocol to identify the cases that must be handled by the physician and potential emergencies. In addition to the general telephone problems , pediatric telephone advice poses special problems that are beyond the scope of this book. [Schmitt BD: Pediatric Telephone Advice. 2nd ed. Boston: Little Brown; 1998.]
When the physician on call has not had an uninterrupted meal or night’s sleep in a week, it is easy to forget that one cannot look at a rash, listen to a chest, or palpate an abdomen over the telephone. The mother’s description is not a substitute for a physical examination. If the child potentially has any condition where proper care decisions would require a physical examination, the child should be sent to the office or the emergency room immediately. If the mother is unreliable, then her descriptions over the telephone are also suspect. If the mother is reliable, then she would not call late at night unless she has a serious concern.
Juries will be unsympathetic to a physician’s claims unless the medical record carefully documents the child’s condition and the physician’s plans. The problem is that many physicians keep sketchy records on children with minor illnesses. These records are adequate for the vast majority of patients who are not seriously ill, but they may mask the progress of a severe illness. This increases both the chance of prolonging the misdiagnosis and the probability that a jury will rule against the physician. Physicians caring for children must make a special effort to record the presence and absence of diagnostic signs that indicate serious illness.