Kansas – Pediatrics – Inability To Diagnose Patient And Use of Improper Medications Due To A Lack of Documentation/Diagnostic Testing

On 2/19/2013, a 17-month-old male presented to a pediatrician’s office for his fifteen-month check.  The pediatrician documented a past medical history of transposition of great vessels at three weeks and open heart surgery.  During the appointment, the pediatrician failed to document family history entirely.  The pediatrician’s section is word-for-word the same information as in other patient records.  The pediatrician failed to provide a detail of treatment plan unique to the patient

On 4/10/2013, the patient presented with a chief complaint of progressively worsening cough with concerns for respiratory syncytial virus, and bronchiolitis.  The review of systems documented ENT evaluation and did not assess the heart. No pulse oximetry was performed.  The physical assessment did not document any GI, musculoskeletal, or skin assessments.

On 5/2/2013, the patient presented for nasal congestion and cough for the last two to three days.  No review of systems was documented.  No oximetry was performed.  It is unclear whether budesonide and albuterol were prescribed, although the pediatrician indicated treatments of budesonide and albuterol in his plan.

On 5/13/2013, the patient presented for coughing coupled with wheezing and rales in the chest.  No pulse oximetry was performed.  The pediatrician signed the patient’s record electronically ten days following the patient visit.

On 6/13/2013, the patient presented with chief complaints of croupy cough, very phlegmy, audible wheezing, rales in the chest, and low-grade fever.  No pulse oximetry was performed.  The pediatrician failed to document his impression regarding why the patient has had the same symptoms since 4/10/2013.

The pediatrician signed the patient record electronically on 7/9/2014.

The pediatrician eventually administered Rocephin and IV methylprednisolone, which was identified as being inappropriate.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records and given his failure to prescribe appropriate medications for the patient’s diagnosis.

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 another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pulmonary Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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