On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”). The patient presented with chief complaints of allergies, congestion, and diarrhea. The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone. The Bactrim was prescribed inappropriately for diarrhea. The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.
On 2/19/2013, the pediatrician saw the patient for a follow-up appointment. The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease. The pediatrician did not document his thought process in how reactive airway disease developed in asthma. The pediatrician did not electronically sign the record until 4/11/2013.
On 6/11/2013, the patient presented to the pediatrician for a school physical. The pediatrician failed to document the patient’s asthma. In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013. The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”
The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.
The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.
Date: October 2016
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
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