A GRANDMOTHER’S 9/11 STORY
15 year old girl with a headache
A 15 year old with a headache – what could be bad about that? Well…
We will see 150,000-200,000 patients in our careers. If we play-the-odds on all of them, some will slip through. This patient arrived during the perfect storm of misdiagnosis, how could the physician, MLP and staff have not been distracted – America had just been attacked and the patient was not the old one hurting.
But we do not have the luxury of deciding which type of patient arrives at which time. This unfortunate patient could have arrived during the multi-car MVA trauma alert, during the Sunday early afternoon church rush, or on 911…
Twice in the initial record by the physician assistant there are two statements regarding the review of systems. The chart clearly states that the review of systems are either “not pertinent” to the patient’s presenting medical problem or were unable to be attained because of the mental status of the patient. The physical exam,however, states that this patient was alert and oriented, which negates any deficiency in their mental status (or was inappropriately charted from an automated computer system). Also the fact that the review system points made by the nurse, such as stiff neck, were not mentioned in the physician assistants HPI makes it clear that this aspect of the patient’s chart was merely for billing purposes and not to clarify their medical condition .