Trauma and child abuse. The importance of the medical record
G. Solomons
A chart audit was undertaken to ascertain the content and quality of
documented information present in medical records of patients with
traumatic injuries seen in a tertiary care hospital. Of the records of
children younger than 6 years of age with a diagnosis of fracture, burn,
contusion, or intracranial injury seen in the inpatient or outpatient
services during a one-year period, 60% contained inadequate data on which
to determine retrospectively if the medical diagnosis of child abuse was
ever considered. The medicolegal implications of this are discussed.
