Documentation : Documenting the History
It will be important to document who provided the history (parent, caregiver, other responsible adult, or the child) and who was in the room when the history was obtained.
Include historical data and a description of the suspected abuse or neglect. The simplest way to consider your documentation of the history is to be sure to include responses to who, what, where, and if answers are available, how and why. This might include what happened, and what happened next (the chronology events), how the concern arose, was there a disclosure and how that came about (questions asked and responses) and behavioral and emotional responses. An excellent supportive approach to obtaining a history is outlined by Dubowitz et al 2023, and more information can be found in chapters on HISTORY and TRIAGE.
Record specific historical data:
- The date and time of the evaluation should be part of the electronic medical record, and sometimes other information, such as the referral source. Be sure to document the person(s) accompanying the child/adolescent to the medical appointment.
- Review the name, address, professional role, and telephone number of all individuals present during the evaluation.
Review and update the past medical history and document a current review of systems: Location of ongoing health care
- Immunization history
- Previous injuries
- Hospitalizations
- Specific complaints (e.g., vaginal discharge) and nonspecific complaints (e.g., behavior changes, enuresis)
In the setting of physical injury, record:
- The specifics of the mechanism of injury (e.g., height of fall, impacting surface)
- Reported time of the injury and patient’s changes in status since then
- Witnesses(es) to the injury
Record a description of the suspected abuse and the name of the person giving the description.
If the child/adolescent is verbal, able to be interviewed, and has made a disclosure of abuse, record:
- The date and time of the disclosure and the time elapsed since the abuse or injury
- The specifics of the disclosure and to whom it was made
- All statements related to the abuse made by the child/adolescent while in your presence, verbatim
- Whether the child/adolescent's statement was spontaneous; if not, what you asked to elicit the statement
- The emotional and physical state of the child/adolescent at the time of the any disclosures
- The developmental skills of the child/adolescent and any diagnoses or conditions that may affect developmental abilities. In the setting of suspected sexual abuse, developmentally inappropriate sexual knowledge may be compelling supportive evidence that a child has experienced an act he/she is not developmentally capable of understanding or fabricating.
Consider organizing your EHR template to prompt the documentation of this data.
Documenting the Social History
Documentation of a social history as part of a basic medical evaluation can help to provide context for abusive situations and offer background narrative to explain challenging situations. It can be used to help determine further needs for medical and mental health services, community resources, and in some cases, to help identify other related families or family members who need medical evaluations or other support. As with documentation for other aspects of the evaluation, providers should adhere to objectivity and unbiased descriptions of facts (Olson et al 2018). The impact of bias in an investigation resulting from commonly used phrases for documenting social factors and determinants of health cannot be overstated. For example, avoid language such as “lack of compliance.” If possible, instead consider documenting the facts behind incomplete medical care. Individual providers should reflect on their documentation and the potential for stigmatizing language.
