Pediatric trauma documentation. Adequacy for assessment of child abuse
M. C. Boyce, K. J. Melhorn and G. Vargo
Department of Family and Community Medicine, Wesley Family Practice Residency, University of Kansas School of Medicine-Wichita, USA.
OBJECTIVE: To determine how frequently information considered necessary for
identification of potential cases of child abuse or neglect was adequately
documented in cases of pediatric trauma. DESIGN: Retrospective study;
medical record review. SETTING: Tertiary care hospital. SUBJECTS: The study
included 1018 children treated in the emergency department or admitted to
the hospital for trauma during the first 6 months of 1992. MAIN OUTCOME
MEASURE: Physicians' documentation of information pertinent to the
identification of child abuse and neglect. RESULTS: Of the 642 medical
records that met study criteria, 28 (4%) included no history of how the
child's injury occurred. A complete examination was documented in only 209
(33%) of the cases. The presence of a witness at the time of injury and
inquiries about any previous injury were inadequately documented. The color
of the injury was noted in only 57 (9%) of the medical records reviewed.
The injury was consistent with the history in 614 (96%) of the cases. In 41
(6%) of the cases, because of inadequate documentation, reviewers were
uncertain whether child abuse or neglect had occurred. Only 23 cases (4%)
were reported to child protective services at the time of the examination.
CONCLUSIONS: Documentation of pediatric trauma remains inadequate to
differentiate accidental trauma from abuse. Inadequately explained or
repeated injuries in children must be reported as suspected child abuse and
neglect, and those reports should include well-documented histories and
physical examinations by the physician involved.
