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Documentation : Documenting the Diagnosis

Careful documentation of the diagnosis is particularly important because medical jargon is often misinterpreted by investigative authorities:

  • Do not use the term "Rule Out (R/O)" to describe the diagnoses that are being considered. It is often interpreted as meaning that the diagnosis has been ruled out.
  • Do not write "examination negative for sexual abuse" because a normal physical exam does not prove that abuse did not occur.
  • Avoid using the words "alleged" and "rape" because they have specific legal meanings. Non-medical professionals may interpret these words differently than your understanding of them.
  • In the setting of physical abuse, carefully document the reason for the conclusion that injuries were not accidental. Examples include "because of the forces required to produce such injuries, the history given does not adequately explain the child's injuries" and "the history is not consistent with the child's injuries."

Suggested Wording for Documentation of a Diagnosis 

Assessments regarding the physical examination may best be documented through clear descriptions of the findings. Clinical decision rules are helpful in identifying critical points to aid in documentation. For example, a facial bruise in an infant is considered highly suspicious for non-accidental trauma and should be clearly documented and explained in the medical record (Pierce 2021). Interpretations, with documentation of interpretations, can be left to child abuse experts (Kellogg, Farst, Adams 2023 and Lorenz et al 2018).

The following are examples for documenting conclusions regarding suspected child sexual abuse examinations:

When a medical provider does not have experience or expertise in the field of child abuse pediatrics:
“The history obtained reveals risk factors and indicators suspicious for sexual abuse. Interpretation of the evaluation and physical findings is deferred for later review with expert consultation.”
When a history of abuse is obtained from the child, the following impressions may apply:
“The child has given a detailed history to caregiver/parent (or medical provider) with sexual knowledge beyond his/her developmental level.”
When the child does not give a clear, consistent disclosure to the medical provider, the following impressions may apply:
"The child has exhibited (or the caregiver/parent has observed) developmentally inappropriate sexual behaviors which are suspicious for sexual abuse.
When findings are present that are unexplained by the history, the following example may apply:
“The history does not correlate with the physical findings."

Documentation