Public Health Law Map - Beta 5 - Medical and Public Health Law Site

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.
1. Acute Illness Observation Scale
P.L. McCarthy’s technique of evaluating pediatric patients focuses on six easily
observed factors that, taken together, are a sensitive indicator of serious illness in an
infant (see Exhibit 7–1). Ideally, each of these factors would be noted on every
pediatric patient seen for an illness. This could be accomplished by using a rubber
stamp to enter the list into the medical record. Even if the individual factors are not
recorded for each visit, they should always be recorded for patients in whom they are
abnormal:
2. Recording Physical Growth and Development
Carefully recorded charts of a child’s growth and development are critical to
detecting long- term developmental problems and chronic illnesses with gradual
onset. The child’s physical development should be recorded on height and weight
charts. Height and weight should be recorded at regular intervals, and weights should
be taken at every visit. Weights should be measured at every pediatric visit for acute
illness. A physician cannot access hydration or weight loss in a small child if there is
no record of the child’s weight before the onset of the illness.
The data should be plotted at the time they are taken. The most legally damaging
situation is to have height and weight information recorded in the child’s chart but
not plotted. It is impossible to evaluate changes in these data without comparing
them with previous measurements and the norms on the charts. When the physician’s
care is questioned, the plaintiff’s attorney will plot the data to demonstrate to the jury
that the physician should have seen problems.
3. Recording Neuromuscular Development
The child’s neuromuscular development should be tracked with a standard
assessment tool such as the Denver Developmental Screening Test. If these tools are
used conscientiously, they can illustrate subtle developmental problems that might
otherwise go unnoticed. They also allow the early detection of medical problems,
such as hearing impairment, that must be treated promptly to prevent disruption of
the child’s development.
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