Pediatric Hospital Chart: Shaken Baby Syndrome Case
Below is a simulated hospital chart for nursing education purposes. This case demonstrates typical documentation for a suspected non-accidental trauma case.
Patient Background
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."