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Am Fam Physician. 1998;58(9):2155-2156

For the past 10 years, the medical literature has increasingly provided information about physical and behavioral characteristics of child abuse. Thorough documentation of physical findings is critical because the medical record is a legal document. A 1980 study on trauma and child abuse stated that adequate documentation of child abuse should include a history and description of the injury, information about previous injuries, and a decision about whether the history and the injuries are compatible. Limbos and Berkowitz conducted a retrospective chart review of emergency department records from 1980 and 1995 to determine if increased awareness and training has improved documentation of suspected child abuse.

A county hospital's emergency department medical records from 1980 and 1995 were included in the study if they specified a discharge diagnosis of “child abuse” or “nonaccidental/intentional trauma.” Children with diagnoses of neglect or sexual abuse were excluded from the review. Information about the patient's history, results of physical examination, diagnostic procedures, diagnosis and final disposition were obtained from each record.

Of the 25,500 children evaluated in the emergency department in 1980, 44 children met the diagnostic criteria for review. Of the 25,470 children evaluated in the emergency department in 1995, 31 children met the criteria, and 29 charts were available for review. Documentation did not differ significantly between the two groups. While the specific injury or reason for evaluation was documented consistently in both years, more than 75 percent of all charts lacked information about witnesses to the alleged abuse. Whether there was a history of previous injury was noted in 59 percent of the 1980 charts, but in only 45 percent of the 1995 charts. Developmental history was not included in any of the records. The location of physical injury was well documented in both years, but only about one third of the 1980 charts fully described these injuries, compared with more than one half of the charts in 1995.

Examination of the genitalia was performed only about one half of the time in either year. Records of laboratory studies were similar in both sets of records. However, skeletal surveys were performed in more than 80 percent of children in 1980, but in only 38 percent of children in 1995. This finding may be explained by the fact that these examinations are not generally recommended now except in children younger than two years. Charts from 1995 were more likely to include a discharge plan than were records from 1980.

The authors conclude that overall documentation of child abuse did not improve significantly between 1980 and 1995. Despite improvements in recording the discharge plan, omissions in important historical information and physical findings still exist. They suggest the use of structured forms and standardized checklists to improve documentation. Teaching rounds in the emergency department could provide a forum for residents and physicians to discuss errors, omissions and ambiguities in actual records. In addition, the authors suggest that a camera be available in every emergency department to improve documentation of alleged abuse.

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Copyright © 1998 by the American Academy of Family Physicians.

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