A 17-month-old girl was brought to Pediatrician A for complete vaccinations on October 20. This visit was documented as “vaccines only.”
The patient’s history included an elevated bilirubin and mild jaundice at birth, secondary to Rh incompatibility with her mother. The child was treated for those conditions at age 11 and 12 months. At that time, she was diagnosed with feeding difficulties, and her parents were educated on diet and fluid intake.
At 14 months, the child was eating table food, drinking whole milk, and taking a multivitamin with iron.
This was the patient’s first visit to Pediatrician A, who noted the child was 17 months old with age-appropriate motor and social skills. The parents reported that she was consuming 24 to 32 ounces of whole milk daily and was taking a multi-vitamin with iron.
Pediatrician A educated the parents on diet and milestones, and administered the vaccines.
On January 26, the patient returned to receive vaccinations for DPT and IPV. At this visit, the parents claim they told Pediatrician A that their daughter had a speech delay, but their concerns were not addressed.
The patient was next seen on April 27 for a hepatitis vaccination. The mother claimed that she again advised Pediatrician A of the speech delay, and insisted that she order labs to test the child for anemia. She told the mother that this was not necessary.
Pediatrician A disputes that this conversation took place, and testified that she suggested the parents contact Early Childhood Intervention for speech therapy. Pediatrician A told them to keep giving the child milk and consider a lifestyle change to help improve her behavior.
Seven months later (at age 30 months), the patient was taken to an urgent care center for shortness of breath. The treating physician observed extreme pallor, labored breathing, and tachycardia. The parents reported she was vomiting and anorexic, but denied history of fatigue or weight loss. They were instructed to take the child to a nearby emergency department (ED).
At the ED, the child was tachycardic with grunting respirations. The parents reported that she had a decrease in appetite over the past four to five days with low urine output. The child still drank milk. Labs revealed a hemoglobin level of 2.0 and a hematocrit level of 7.2. An EKG showed tachycardia with possible left ventricular hypertrophy, and an x-ray showed pulmonary edema.
The child was transferred to a children’s hospital and diagnosed with congestive heart failure. The history on admission indicated that the child was pale over the last six months. In the last two months before admission, she was fatigued and short of breath on exertion. She had little appetite and would only drink whole milk.
The patient underwent multiple blood transfusions; was intubated and later developed bradycardia; was found to have left ventricular/atrial dilation and moderately depressed left ventricular function. This was consistent with high output cardiac failure.
The patient was diagnosed with severe anemia resulting in congestive heart failure, hepatomegaly, generalized weakness, and deconditioning. The anemia was described as secondary to nutritional deficiency.
After three weeks in the hospital, the patient was discharged. She was seen by a pediatric neurologist. An MRI of the brain revealed nutritional depravation. The pediatric neurologist’s assessment was feeding difficulties and mismanagement that were improving with a feeding therapist, iron deficiency anemia, and expressive language disorder.
A pediatric cardiologist also followed the patient, who was reported to be improving in her development and condition.
A lawsuit was filed against Pediatrician A. The allegations were:
- failure to screen for anemia during well checks;
- failure to instruct about the child’s milk consumption and nutrition; and
- failure to adequately observe, diagnose, and treat the patient.
The plaintiff’s expert was critical of Pediatrician A in four areas:
- failure to perform a well-child exam on the first visit;
- failure to properly document the findings during each visit;
- failure to recognize symptoms of anemia; and
- failure to screen the patient for anemia.
Physicians who reviewed the case for the defense pointed out that the patient’s first visit at 17 months was to start vaccinations; therefore, the visit was limited in scope. Had the family brought the patient for an 18-month well check, this visit would have included anemia screening.
Subsequent visits in January and April were also for vaccines only. Had a 24-month well check been scheduled, it would also have included screening for anemia.
The plaintiffs argued that Pediatrician A’s failure to address the patient’s milk intake contributed to her anemia. However, defense consultants were adamant that an extra 8-ounce glass of milk per day would not cause anemia or any other life-threatening conditions. The medical literature supported defense experts’ opinions.
Regarding causation, reviewers theorized that the child’s condition was due to several factors, such as extended periods of malnutrition. One expert testified that because the patient had neo-natal anemia for which there was no follow up, it was possible she would experience future hematologic or metabolic problems.
Documentation was a weakness in this case. Pediatrician A’s chart did not include information about the patient’s growth, vital signs, and “standard health maintenance.” Also missing was documentation of discussions with the parents about the child’s diet, or the request for lab work to check the patient for anemia. The records also did not reflect that the pediatrician recommended or scheduled a 24-month well check for the patient.
This case was settled on behalf of Pediatrician A. The lack of documentation contributed to the decision to settle the case.
Risk management considerations
When a claim is filed against a physician, all medical records and documentation regarding the care of the patient become central to the defense. All too often, the lack of comprehensive and contemporaneous entries in the medical record compromise that defense.
To comply with Texas Medical Board Rule 165.1, an “adequate medical record” is expected to include:
- reason for the encounter and relevant history, physical exam findings, and prior diagnostic test results;
- past and present diagnoses;
- an assessment, clinical impression, or diagnosis;
- plan of care; and
- the date and legible identity of the observer.
If the elements above are not in the record, conjecture and reliance on memory can hinder the defense of the case.
For a complete list of the TMB rules for medical records, visit http://www.tmb.state.tx.us/page/board-rules.