On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented. A family history was documented; however, no detail of family history was documented. The patient was not seen until eleven days after discharge.
On 7/3/2013, the patient presented to the obstetrician for her four month well exam. At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota. No consent form for the aforementioned vaccines was found in the record.
On 9/10/2013, the patient presented to the obstetrician for her six-month exam. The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.
The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.
The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.
Date: October 2016
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
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