Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it’s important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in “normal patient” macros that are inappropriate for pediatric patients.
Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.