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Documentation : Documenting Other Information

Additional information that should be documented in the medical record includes:

  • All reports or attempts to report to the State Central Register, including:
    • The name of the person making the report
    • The name of the person accepting/rejecting the report
    • The time and date of the report
    • The assigned case number, if available
  • The name and unit of the assigned Child Protective Service worker and the name, precinct, and badge number of any police officers that become involved. This information may not be available if an investigation is just being initiated.
  • Referrals for ongoing medical care, mental health services, victim advocacy services, and law enforcement services
  • Discharge instructions and the caregiver's level of understanding

Documentation