History

Every medical evaluation includes obtaining a history from the patient and family. Healthcare providers ask questions related to suspected abusive incident(s) and document the responses in the electronic medical record, including tables and checkboxes and a clear, chronological narrative. In addition, the medical history is a valuable aspect of the evidence collection process because the child/adolescent may more readily discuss such issues as genital pain or other genitourinary symptoms and disclose abuse to a trusted medical provider. When child maltreatment is suspected, the main goals of the medical history are to:

  • Obtain information to assess possible injury or infection
  • Determine the presence of possible medical symptoms that may or may not be related to the abuse
  • Evaluate the child/adolescent's emotional state 
  • Evaluate the child/adolescent's cognitive, developmental, language, and social levels
  • Assess safety, particularly regarding potential discharge to the home environment
  • Support the non-offending caregiver
  • Develop a differential diagnosis for any symptoms
  • Document critical information for legal purposes

When a parent or caregiver brings their child to the primary care or other medical provider with a concern about abuse, care should be taken create a space for the discussion that is out of earshot of the child. Discussing the abuse in front of the child has the potential to influence the child’s behavior and/or future disclosure.

The medical history is not an investigative interview or a forensic interview. Unless the medical professional is a trained forensic interviewer and is the one performing a forensic interview, the medical history should supplement information obtained by authorities.

If the child/adolescent has had an investigative interview, consult with the referral source prior to taking the medical history. In addition, inquire if there are previous medical records, including ED records; previous or current Child Protective Services reports; police reports; or school nurse records. This can significantly shorten the history taking process and prevent trauma from repeated questions and/or interrogations. 

In some circumstances, the medical history and investigative interview may be conducted together.

For further information on investigative interviewing, see Child Forensic Interviewing: Best Practices https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/248749.pdf and Forensic Interviewing: A Primer for Child Welfare Professionals https://www.childwelfare.gov/resources/forensic-interviewing-primer-child-welfare-professionals/.

Key Concepts

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