TTD 2: Documenting pediatric specific orders
- This EPA focuses on written documentation of orders for assessment and management of any patient, after discussing the case with supervisor or a senior resident.
- This includes taking into account patient characteristics to adapt the assessment plan and/or dosing, and using the appropriate order structure and local order entry system.
- This EPA includes ordering diagnostic tests as well as treatments, such as intravenous fluids, medications, and diet/nutrition.
- This EPA may be observed in simulation.
Review of clinical documentation by supervisor or senior resident
Use form 1. Form collects information on:
- Age: neonate; infant; preschool; school age; adolescent
- Clinical setting: inpatient; outpatient; emergency department; community; simulation
- Type of orders: medication/prescription; intravenous fluids; diet/nutrition; diagnostic tests; other (please specify)
Collect 6 observations of achievement.
- A variety of age groups
- At least 1 neonate/infant
- At least 1 child/adolescent
- At least 1 medication/prescription order
- At least 1 intravenous fluids order
- At least 1 diet/nutrition order
- At least 3 observations by supervisor
- COM 5.1 Document patient care orders
- ME 2.4 Adjust medication dosing for patient age, size and/or other relevant factors
- COM 5.1 Organize information in appropriate sections
- ME 2.1 Recognize situations requiring direct communication of orders to the appropriate team member
- P 1.1 Complete assigned responsibilities in a timely fashion