Baby Thomas Johnson, a 6-month-old infant, was rushed to Memorial Children's Hospital by EMS after his babysitter called 911 reporting he was "shaking and not responding normally."
9:15 AM
Single mother Jessica Johnson drops Thomas off with babysitter Ms. Peterson before her shift at the local diner.
2:30 PM
Ms. Peterson calls 911 reporting Thomas became suddenly lethargic after "crying for hours."
2:45 PM
EMS arrives, finding Thomas unresponsive with irregular breathing. They initiate emergency transport.
3:10 PM
Thomas arrives at Emergency Department. Ms. Peterson states "he just wouldn't stop crying."
Patient Chart: Suspected Shaken Baby Syndrome
This case demonstrates critical documentation requirements in suspected child abuse. Note the objective presentation of findings without premature conclusions.
Patient Arrival Simulation
EMS: "6-month-old male, unresponsive at scene. Caregiver said he 'wouldn't stop crying.' Seizure activity observed during transport."
Triage RN: "I note bruising on upper arms. Respirations irregular. No reported falls."
EMS: "O2 sat 92% en route. Caregiver gave inconsistent accounts of what happened."
Triage RN: "Priority assessment. Let's get him to Trauma 1 immediately."
Documentation must be objective, timely, and thorough. Each provider's notes create a comprehensive clinical picture essential for both medical care and potential legal proceedings.