Abusive Head Trauma
- Physical examination findings, preferably in words, diagrams and images;
- Summary and interpretation of screening blood tests for bone metabolism, coagulation and other trauma markers (liver injury);
- Summary and interpretation of imaging studies, including method, timing and specific locations of any bleeding and brain and bone injuries;
- Summary and interpretation of evaluations done to rule out other potential nonabusive causes (e.g. consistency of reported minor trauma);
- Overall diagnostic summary regarding injuries and cause (e.g. abusive head trauma, physical abuse, inflicted traumatic brain injury).
Accessible Version
Given the legal implications of AHT, case documentation is important to show how the evaluation was done, the other things that were ruled out and the description of the totality of the findings. This includes describing the physical examination findings, preferably in words, diagrams and images; giving a summary and interpretation of screening blood tests for bone metabolism, coagulation and other trauma markers (liver injury);, giving a summary and interpretation of imaging studies, including method, timing and specific locations of any bleeding and brain and bone injuries and the evaluations done to rule out other potential nonabusive causes (e.g. consistency of reported minor trauma); It is important to specifically include a diagnostic summary regarding injuries and their cause (using terms such as abusive head trauma, physical abuse, or inflicted traumatic brain injury).
