Pediatric trauma documentation - Adequacy for assessment of child abuse

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.