CHAMP Education for Child Abuse Medical Providers

Accessible Version

In terms of documentation, I just want to highlight that when you're obtaining a history and then documenting it in a medical chart, it is important to say who you obtained the history from. Sometimes family members are not at the bedside with the patient, so you may be obtaining all of your history from the chart. Or perhaps you are obtaining it from a family friend or even a CPS worker. Physical exam. The most important thing to consider is, especially if there are skin findings. Is the way that they're documented so it would be standard to document the location of the finding, the morphology. The size of the finding, including a measurement using a ruler, the color of the finding. And I also always consult medical photography if they are available or obtain digital photos that are stored securely in our system. Because the picture can become so illustrative with the systems and the other agencies that we work with.