Medical Record Review

Abstract

The Guide for Record Review of the American Board of Pediatrics that accompanies this issue of Pediatrics in Review deals with anemia, a disorder that shares with many other conditions the potential for generating a large amount of laboratory data. Specimen by specimen, these facts can accumulate to a surprising extent. Properly organized, the data can demonstrate clinical trends and provide specific pieces of information needed for immediate management decisions. Left to pile up in the back of the chart or scattered throughout the progress notes, the data will form a jumbled briar patch that severely limits the utility of the information and fails to give an overview. The familiar immunization summary sheet demonstrates nicely how much time and effort can be saved when data are recorded in an organized way. Most children do not require the services of the laboratory often. The occasional data sheets that come in can be put at the back of the progress notes and quickly scanned if a particular fact is needed. Certain values, such as hematocrit or blood lead level, that are generated as part of normal screening procedures can be recorded in a designated area on the immunization sheet. For children who have "laboratory-intensive" disorders, more is needed.