Let the Record Speak: Medicolegal Documentation in Cases of Child Maltreatment

Children often present to emergency departments for evaluation and treatment of injuries or conditions that result from abuse. When child abuse is suspected, the physician must document the history, examination, medical impression, and report those concerns to the appropriate agency. Although physicians are often the first identifiers of abuse, the literature confirms that there is inadequate medical documentation for suspected child abuse victims. What is written in the medical record for these children significantly contributes to the success or failure of investigations and litigation. More importantly, however, medical documentation can ultimately impact the future of children who have suffered abuse. Therefore, emergency physicians must know what to document and put it into practice.

Keywords: medical records, child abuse, documentation, medicolegal aspects