I
1Medical
--
GOALS
ties that are not particularly interesting to him or her, or do not demand
OF THE MEDICAL
RECORD
Record
SECTION
his or her full attention. Certainly, a first generalized seizure, as well as any other kind of seizure, also may occur outside the home.
Demonstrate inclusion of all relevant data for a given condition, Induding that obtained by telephone. Demonstrate the value of gathering eyewitness Information in constructing an accurate history. Demonstrate the importance of teaching patients about their conditions and of documenting educational efforts. Demonstrate the value of a medication record for keeping track of long-term drug therapy and ancillary data.
Because curs away
seizure activity often ocfrom home, parents and
physicians
may be dependent
the observations
of other
scniption
activity
distorted
by the time
gets
to the pediatrician.
that eyewitness
to get the full picture of the illness; the extra effort to get a true account is well
the spells
eral pediatricians eventually treat this chronic condition, and there are important lessons to be learned in the process. In the sample record that follows, the initial observations of the patient’s brief spells were made by the schoolteacher. Because a child spends so much time in school and is under the direct scrutiny of teachers, it is not surprising that subtle signs of illness firstmay be picked up in that setting. Interestingly, absence seizures are more likely to occur when the child is engaged in activi-
Vol.
13
No.
2
February
be
applies to a host as well, such as
lihood
of a normal
stressed;
were
here,
ongoing,
where
the teacher
in a letter.
A telephone call, made the time of observation
as close to as possible,
be preferable
in the case of a
solitary incident to minimize memory loss of the witness. Prospective observations are valuable, and the par-
ents of this patient
were
asked
to
watch carefully over the weekend, leading to corroboration of the teach-
er’s description. It is often helpful for parents to construct a prospective diary of an ongoing problem, such as headaches or abdominal pain. Another lesson to be learned from treating seizures is the importance of teaching the patient and family about a long-term illness, and a teaching plan and concomitant record of what has been covered can enhance the quality of care. Both child and family need to have the seizure disorder put into the perspective of the child’s whole life experience. The high like-
life should
at the same
time,
be
the neces-
sity for long-term treatment and monitoring of clinical status require emphasis. Drug effects, guidelines for activity, and precipitating factors of seizures are among the topics the physician
should
cover.
Most pediatric patients do not take medication chronically. Children who have seizures are an obvious exception, and changes in drugs or dosages are common. Accurate knowledge of the child’s current regimen is critical for proper interpretation of clinical status and to avoid adverse drug interactions if something else is prescribed. A physician prescribing erythromycin
for an infection,
for ex-
ample, must know if the patient is taking carbamazepine because the antibiotic may raise the level of the anticonvulsant.
presented
his observations
would
Accompanying this issue of Pediatrics in Review is the American Board of Pediatrics’ Guide for Record Review dealing with seizures. All gen-
accounts
injury.
supplied
Lessons to Learn from the Treatment of Children Who Have Seizures
the
It is
critical
In the case
Review
may
gathered patient’s needed
head
in Review
in-
of the seizure
be severely
spent. This lesson of other conditions
Pediatrics
people,
cluding other children, teachers, coaches, or strangers who happen by. Consequently, the all-important de-
story
Record
upon
I
:-----
Clear
delineation
of
current medications is especially important when several providers might be involved in the child’s care. The medication record also will simplify the provision of refills and can be used to document when drugs are refilled. At the end of the sample
record
that follows is an example of a simple medication record that can tell the physician at a glance what the child is taking (Figure, page 76). A section for comments allows for additional data, such as blood chemistries and brief notations of clinical status. Although not intended to be a formal flow sheet or a comprehensive record of the child’s illness, the medication record can perform some of the functions of a flow sheet and provide an overview of the child’s clinical course. Lawrence Associate
F. Nazariam, Editor
1992
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
MD
75
Medical Record Review: Lessons to Learn from the Treatment of Children Who Have Seizures Pediatrics in Review 1992;13;75 DOI: 10.1542/pir.13-2-75
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/13/2/75
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
Medical Record Review: Lessons to Learn from the Treatment of Children Who Have Seizures Pediatrics in Review 1992;13;75 DOI: 10.1542/pir.13-2-75
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/13/2/75
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
1Medical
--
GOALS
ties that are not particularly interesting to him or her, or do not demand
OF THE MEDICAL
RECORD
Record
SECTION
his or her full attention. Certainly, a first generalized seizure, as well as any other kind of seizure, also may occur outside the home.
Demonstrate inclusion of all relevant data for a given condition, Induding that obtained by telephone. Demonstrate the value of gathering eyewitness Information in constructing an accurate history. Demonstrate the importance of teaching patients about their conditions and of documenting educational efforts. Demonstrate the value of a medication record for keeping track of long-term drug therapy and ancillary data.
Because curs away
seizure activity often ocfrom home, parents and
physicians
may be dependent
the observations
of other
scniption
activity
distorted
by the time
gets
to the pediatrician.
that eyewitness
to get the full picture of the illness; the extra effort to get a true account is well
the spells
eral pediatricians eventually treat this chronic condition, and there are important lessons to be learned in the process. In the sample record that follows, the initial observations of the patient’s brief spells were made by the schoolteacher. Because a child spends so much time in school and is under the direct scrutiny of teachers, it is not surprising that subtle signs of illness firstmay be picked up in that setting. Interestingly, absence seizures are more likely to occur when the child is engaged in activi-
Vol.
13
No.
2
February
be
applies to a host as well, such as
lihood
of a normal
stressed;
were
here,
ongoing,
where
the teacher
in a letter.
A telephone call, made the time of observation
as close to as possible,
be preferable
in the case of a
solitary incident to minimize memory loss of the witness. Prospective observations are valuable, and the par-
ents of this patient
were
asked
to
watch carefully over the weekend, leading to corroboration of the teach-
er’s description. It is often helpful for parents to construct a prospective diary of an ongoing problem, such as headaches or abdominal pain. Another lesson to be learned from treating seizures is the importance of teaching the patient and family about a long-term illness, and a teaching plan and concomitant record of what has been covered can enhance the quality of care. Both child and family need to have the seizure disorder put into the perspective of the child’s whole life experience. The high like-
life should
at the same
time,
be
the neces-
sity for long-term treatment and monitoring of clinical status require emphasis. Drug effects, guidelines for activity, and precipitating factors of seizures are among the topics the physician
should
cover.
Most pediatric patients do not take medication chronically. Children who have seizures are an obvious exception, and changes in drugs or dosages are common. Accurate knowledge of the child’s current regimen is critical for proper interpretation of clinical status and to avoid adverse drug interactions if something else is prescribed. A physician prescribing erythromycin
for an infection,
for ex-
ample, must know if the patient is taking carbamazepine because the antibiotic may raise the level of the anticonvulsant.
presented
his observations
would
Accompanying this issue of Pediatrics in Review is the American Board of Pediatrics’ Guide for Record Review dealing with seizures. All gen-
accounts
injury.
supplied
Lessons to Learn from the Treatment of Children Who Have Seizures
the
It is
critical
In the case
Review
may
gathered patient’s needed
head
in Review
in-
of the seizure
be severely
spent. This lesson of other conditions
Pediatrics
people,
cluding other children, teachers, coaches, or strangers who happen by. Consequently, the all-important de-
story
Record
upon
I
:-----
Clear
delineation
of
current medications is especially important when several providers might be involved in the child’s care. The medication record also will simplify the provision of refills and can be used to document when drugs are refilled. At the end of the sample
record
that follows is an example of a simple medication record that can tell the physician at a glance what the child is taking (Figure, page 76). A section for comments allows for additional data, such as blood chemistries and brief notations of clinical status. Although not intended to be a formal flow sheet or a comprehensive record of the child’s illness, the medication record can perform some of the functions of a flow sheet and provide an overview of the child’s clinical course. Lawrence Associate
F. Nazariam, Editor
1992
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
MD
75
Medical Record Review: Lessons to Learn from the Treatment of Children Who Have Seizures Pediatrics in Review 1992;13;75 DOI: 10.1542/pir.13-2-75
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/13/2/75
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
Medical Record Review: Lessons to Learn from the Treatment of Children Who Have Seizures Pediatrics in Review 1992;13;75 DOI: 10.1542/pir.13-2-75
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/13/2/75
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at Karolinska Insttitutets Bibliotek on May 26, 2015
