Sentinel Injuries
- Assessment and plan
- List all pertinent injuries and/or findings
- Provide a differential diagnosis
- Clearly state level of concern for child physical abuse +/- neglect
Accessible Version
When I write a consult note, it's obviously also going to include an assessment and plan. And in that assessment and plan.
I list all the pertinent injuries and or findings. So even if I've documented them in the physical exam.
Or discuss them in the HPI, perhaps. I still bring them all down into the assessment and plan because I think there's a lot of clinicians and other professionals that we work with who go straight to the assessment of our notes.
I provide a differential diagnosis. And again, that usually is looking at non-accidental trauma accidental trauma and or medical mimics of a finding.
I also clearly state my level of concern for child physical abuse and or neglect.
And if you're listening to this and you're listening to this unable to comment on your level of concern for child maltreatment. This would be an opportunity to refer a patient to a child abuse medical professional, who has expertise in this particular field.