PEDIATRIC TRAUMA DOCUMENTATION - ADEQUACY FOR ASSESSMENT OF CHILD-ABUSE

Objective: To determine how frequently information considered necessar y for identification of potential cases of child abuse or neglect was adequately documented in cases of pediatric trauma. Design: Retrospect ive study; medical record review. Setting: Tertiary care hospital. Sub jects: The study included 1018 children treated in the emergency depar tment or admitted to the hospital for trauma during the first 6 months of 1992. Main Outcome Measure: Physicians' documentation of informati on 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 witn ess 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, becaus e of inadequate documentation, reviewers were uncertain whether child abuse or neglect had occurred. Only 23 cases (4%) were reported to chi ld protective services at the time of the examination. Conclusions: Do cumentation of pediatric trauma remains inadequate to differentiate ac cidental trauma from abuse. Inadequately explained or repeated injurie s in children must be reported as suspected child abuse and neglect, a nd those reports should include well-documented histories and physical examinations by the physician involved.