Inadequate documentation and poor communication in pediatrics can result in significant harm for children. All treating professionals need to be in close communication in pediatric patient care, and in the absence of live conversations, require extensive documentation through medical records-keeping to understand the current situation. When communication breaks down, or complete and accurate records about a child’s medical condition do not exist or are otherwise inaccessible, doctors and other healthcare providers cannot fulfill their obligation to uphold the proper standard of care, primarily because they have insufficient information to form an accurate diagnosis and appropriate treatment plan. Without a proper diagnosis, treatment may even harm a young patient, rather than help.
Common Examples of Poor Documentation and Communication in Pediatric Care
Far too often, insufficient physical examinations, history intake, and questions regarding inherited conditions leave gaping holes in the pediatric patient’s medical records. This makes every consultation that follows less productive and may even lead to the child suffering serious complications or injuries. As such, physicians must pay attention to everything said and noted through observation, especially with babies and young children, as well as listening to their parents’ reports to clarify symptoms. Then, all of this information must be documented through extensive medical record-keeping, to aid each and every provider in the healthcare chain in delivering correct and timely care.
Inadequate Patient History and Initial Exam Failures
Some documentation and communication failures occur during consultations when medical professionals record incomplete patient histories for lack of patience, communication skills, and cultural sensitivity. Young patients may not be able to communicate their symptoms, so physicians rely on third-party information related to them by parents, nurses, and other doctors. As such, healthcare providers who make patients and families feel part of the team foster better communication. Often, physicians and nurses do not make patients and their families feel like partners in the healthcare process. They mistakenly exclude the child’s parents from the discussion and overlook the importance of patient empathy, asking the right questions, and taking copious notes regarding the child’s physical and mental state during initial and subsequent consultations.
As one might expect, pediatric patients and parents are able to disclose more potentially valuable information about signs and symptoms when they feel heard and their doctor takes time to listen. However, it is the responsibility of the healthcare providers involved to take the time, ask the right questions, and patiently explore all of the information reported. Since parents are not necessarily educated in the medical field, they may not be aware of which questions to ask their child’s pediatrician, urgent care doctor, emergency room physician, or specialist. Likewise, it is less likely that parents know what information may be important to ensure accurate diagnosis of their child’s case.
Lack of Communication with Instructions and Follow Up
Following the initial consultation and any treatment at the medical facility itself, children and their parents can obey doctor’s treatment orders, resulting in better outcomes, when they understand what to do. Informed parents who know what to look out for when their child is ill or recovering from a procedure, can prevent delays when dealing with possible complications and necessary visits to emergency rooms. For instance, when physicians return post-surgery calls, this can help parents and caretakers distinguish between normal symptoms from surgery and dangerous infections. Conversely, by failing to ensure patient caretakers understand hospital discharge instructions or what to be on the look-out for, physicians can contribute to serious, worsening infection and sepsis. Clearly, follow-up is critical, particularly when treating newborns and children.
When parents call their doctor’s office to report their concerns, the medical team must listen with care and document everything accordingly. In addition, medical staff must know when to pass on that information to the doctor to prevent emergencies like allergic reactions, growing infections, or blocked airways. Likewise, physicians must respond quickly to nurses requesting that they assess an infant or child in the hospital, clinic or office. The sooner the doctor is informed of a child’s changing condition, the more successful they can be in preventing injury with proper medical intervention. This applies not only to patients and their parents with providers, but also providers when communicating with other providers.
Not only effective communication, but careful documentation, also contributes to better patient assessments, more accurate and timely diagnosis, and proper treatment. Good record-keeping allows other treating physicians to know what has been done with a child thus far and what treatment must follow. It also helps referred specialists make better diagnoses when histories, after care instructions and clinical impressions are thorough, detailed, and clear. Effective documentation also promotes better tracking of tests and referrals. When records are flagged for patient reminders about taking tests or seeking referrals, patient lives may be saved. And when test results do come in, quickly delivering them to the appropriate party is equally important. For example, not following up on radiological tests or pathological report can mean a missed diagnosis. This is extremely harmful when the child is suffering from a condition requiring immediate treatment, such as cancer, pneumonia, appendicitis, or meningitis.
Negligence with Electronic Medical Records
Not only lack of documentation, but negligent record-keeping may lead to errors that spell extremely negative outcomes for children. While electronic medical records (EMR’s) are convenient, keeping all patient records in one place, they can interfere with patient-physician communication and create disastrous medical errors leading to child injuries. For instance, typing patient histories and symptoms while the child or parent relays them at the office visit is distracting, as the physician is unable to fully pay attention and observe the physical and emotional cues that may provide further insight into the child’s condition. Additionally, the EMR system is prone to errors, as its primary function is adding information, not removing it, which may potentially carry over incorrect or outdated information system-wide. Other errors result when providers first learn the system, transitioning from paper to a computerized system, which may cause information to be lost or incorrectly assigned to the wrong patient.
Has Your Child been Injured by Documentation or Communication Errors? An NJ Lawyer is Here for You
Ultimately, many pediatric medical errors result from poor communication and documentation, and the costs of these mistakes can be far too high for children and their families. In fact, failing to document or communicate creates precarious broken links in the healthcare system, the result of which can be a child’s worsening condition or even permanent harm. While a pediatrician or another doctor may have a great deal of medical knowledge, if they cannot clearly and conscientiously document their impressions and findings, or communicate with their staff, other doctors, or you, then they may hurt your child. This reality may have already come as an unwelcome shock if your child has been injured.
If this applies to you and your family in New Jersey, our highly qualified pediatric malpractice attorneys can investigate your child’s case and determine if medical negligence, indeed, contributed to your child’s complications. If a physician’s, hospital’s or medical staffer’s neglect constitutes malpractice, we can assist you with holding them accountable and seeking just compensation. Contact us at (866)-708-8617 for a free consultation and let us help you put the law to work on your child’s behalf.