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The Importance of the Medical Record

Gerald Solomons, MD

Am J Dis Child. 1980;134(5):503-505.

Abstract
• 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.

(Am J Dis Child 134:503-505, 1980)

Author Affiliations
From the Department of Pediatrics; the Child Development Clinic; and the Region VII Child Abuse and Neglect Resource Center of the Institute of Child Behavior and Development, University of Iowa, Oakdale.

Footnotes
Reprint requests to Region VII Child Abuse and Neglect Resource Center, Institute of Child Behavior and Development, University of Iowa, Oakdale Campus, Oakdale, IA 52319 (Dr Solomons).

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