The pediatric patient often presents not only a diagnostic challenge, but a documentation challenge as well. Between the different pediatric departments within a hospital, there may be tremendous variation in how the pediatric patient’s medical record is documented. An incomplete or inaccurate medical record can be a serious risk management problem and can increase overall risk exposure. It is critical for practitioners to communicate with their team and with parents or caretakers, and complete thorough documentation in the medical record.
In this activity, we discuss medical-legal medicine vs. medical-legal documentation, the challenges of triage with pediatric patients, incorrect/correct use of the terms lethargy and irritability, and qualifying and quantifying pertinent positives and negatives. We also take a brief look at some of the diagnoses in pediatric emergency medicine that commonly result in malpractice claims. After completing this activity, practitioners should be able to: demonstrate an understanding of the difference between medical-legal medicine and medical-legal documentation; demonstrate appropriate use of the terms lethargy/lethargic and irritability/irritable in the medical records of pediatric patients; and integrate the qualified and quantified pertinent clinical positives and negatives into the medical records of pediatric patients in order to demonstrate consideration of an appropriate differential diagnosis and decrease allegations of medical negligence.
- Provider:The Sullivan Group
- Activity Link: https://www.thesullivangroup.com/RSQSolutions/course-purchase-home/
- Start Date: 2023-03-20 05:00:00
- End Date: 2023-03-20 05:00:00
- Credit Details: AMA PRA Category 1 Credit™️: 2.0 hours
- Commercial Support: No
- Activity Type: Enduring Material
- CME Finder Type: Online Learning
- Fee to Participate: Variable
- Measured Outcome: Learner Competence, Learner Knowledge, Learner Performance, Patient Health
- Provider Ship: Directly Provided
- Registration: Open to all