Documentation
The medical record of a child or adolescent who has been evaluated for suspected child maltreatment or neglect is an important document that will almost certainly be examined by other parties, often as part of a court proceeding. The information will be needed by consultants, such as child abuse pediatricians, and other potentially involved healthcare and investigative personnel. It is vital that the information be recorded accurately and completely. The results of the medical evaluation must be summarized carefully and in unambiguous language. For more information about documentation, see LEGAL ISSUES : Release of Medical Records.
Primary care medical providers are in a unique position to recognize and document concerns and risk factors for child abuse as well as new and suspicious findings. Unfortunately, these findings are not always properly documented. (MacPherson SC, Golonka M, Liu Y, Terrell L, Evans KE, Hurst JH, Gifford EJ. Child Sexual Abuse Documentation in Primary Care Settings. Clinical Pediatrics. 2024; 63 (9) : 1247-1257. (DOI) ). In addition, you might want to consider what should be documented in a record should your patient unfortunately be the subject of child maltreatment or neglect in the future. For example, following up for appropriate health care, growth records, behaviors, and even normal physical findings can be critical in a forensic evaluation where child abuse experts or investigators may be interested in retrospectively reviewing a child’s past medical records. In addition, the continuity of information, when transferred from a primary care provider to a consultant, is critical to good health care.
When a patient presents to their primary care provider or to the emergency department for evaluation for child abuse, the framework will typically follow a basic medical model used for other pediatric conditions. (Keenan HT, Campbell KA. Three models of child abuse consultations: A qualitative study of inpatient child abuse consultation notes. Child Abuse & Neglect. 2015; 43 : 53-60. (DOI) ). Investigative models of interviewing patients and caregivers are generally not recommended in these settings.
The medical record should objectively document findings, diagnoses, an assessment, and a plan. In some cases, opinions or discussion beyond the recorded assessment will be required to assist investigators. These will be in the form of letters, affidavits, or testimony. Investigators may need documentation prior to completion of the medical record. In these situations, a summary letter may be written and the medical record provided to appropriate law enforcement or social services professionals at a later date. When there is a normal examination, it may be necessary to explain why the examination is normal considering the history of abuse.
In some settings, the EHR system is equipped with a pre-programmed data collection system to help screen and document risk factors for injury and/or child abuse. Elements for the data collection and decision tree should be reviewed by an interdisciplinary team on a regular basis to be assured of evidence-based process and design. (For more information, see Thomas A, Asnes A, Libby K, Hsiao A, Tiyyagura G. Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study. Journal of Medical Internet Research. 2024; 26 : e51058. (DOI) and Martin NR, Claypool AL, Diyaolu M, Chan KS, A'Neals E, Iyer K, Stewart CC, Egge M, Bernacki K, Hallinan M, Zuo L, Gupta U, Naru N, Scheinker D, Morris AM, Brandeau ML, Chao S. SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening. Journal of Pediatric Surgery. 2024; 59 (2) : 337-341. (DOI) .) Sharing of information documented in the medical record, including release to the patient and/or caregiver as governed by the 21st Century Cures Act, (National Coordinator for Health IT - ONC’s Cures Act Final Rule) is further described in the section LEGAL ISSUES : Release of Medical Records.
Key Concepts
