Solomons G
Am J Dis Child. 1980 May;134(5):503-5. doi: 10.1001/archpedi.1980.02130170053018.
A chart audit was undertaken to ascertain the content and quality of documented information present in medical records of patients with traumatic injuries seen in a tertiary care hospital. Of the records of children younger than 6 years of age with a diagnosis of fracture, burn, contusion, or intracranial injury seen in the inpatient or outpatient services during a one-year period, 60% contained inadequate data on which to determine retrospectively if the medical diagnosis of child abuse was ever considered. The medicolegal implications of this are discussed.
进行了一项图表审查，以确定在一家三级护理医院就诊的创伤患者病历中记录信息的内容和质量。在一年期间，对住院或门诊服务中诊断为骨折、烧伤、挫伤或颅内损伤的6岁以下儿童的病历进行审查，发现60%的病历所包含的数据不足以让我们回顾性地确定是否曾考虑过虐待儿童的医学诊断。本文讨论了这一情况在法医学上的影响。
