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.
This simulated chart should be used for educational purposes only to help nursing students recognize documentation patterns in suspected abuse cases.
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."
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.
Medical Orders: Suspected Abuse Case
Immediate Actions: Full trauma assessment, CT scan, ophthalmological exam, complete blood work
Documentation: Photograph all injuries, precise measurements, detailed timestamps
Chain of Custody: Label and secure all evidence for potential legal proceedings
Consultations: Neurology, ophthalmology, child protection team, social services
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.