The pediatrician's documentation of child maltreatment
H. Dubowitz and D. C. Bross
Department of Pediatrics, University of Maryland School of Medicine, Baltimore 21201.
Pediatricians are increasingly involved in the assessment of suspected
child maltreatment. These assessments are a crucial component of the
overall evaluation of the patient and provide the basis for interventions
to protect the child. An accurate documentation of the pediatrician's
assessment is important to convey the information to professionals in the
public agencies involved, including the legal system. However, there may be
uncertainty among pediatricians concerning what should be documented in the
medical record in cases of child maltreatment. The objectives of this
article are to provide a detailed but generic description of the
information that should be gathered during the evaluation of children who
show signs of any form of child abuse and neglect and to provide clear
guidelines for the proper written documentation of child maltreatment.
