Bar-on M E, Zanga J R
Department of Pediatrics, Children's Medical Center, Medical College of Virginia-Virginia Commonwealth University, Richmond 23298, USA.
Pediatrics. 1996 Sep;98(3 Pt 1):429-33.
To assess the effectiveness of structured forms in the collection and documentation of information essential to the evaluation of abused children.
Retrospective chart review.
Five hundred sixty-seven children were evaluated for physical or sexual abuse during a 24-month period.
Specific items crucial to the evaluation of abuse were selected for both physical and sexual abuse. By using these items as markers, we compared the data obtained and documented during abuse evaluations after the introduction of the forms with those obtained before their introduction. The information that occurred more frequently when using the structured forms included: a history of the assault from both the child and an adult (and in cases of physical abuse, a developmental history); specific sexual acts; mechanism of injury; a detailed description of the genital examination; drawings of findings (both sexual and physical); documentation of laboratory studies, photographs, and radiographic studies; and reporting to Child Protective Services.
Structured forms significantly increased the information collected and documented in medical records during evaluations of abused children. These forms were found to be more effective than the previously used unstructured, institutional form.
评估结构化表格在收集和记录对受虐儿童评估至关重要的信息方面的有效性。
回顾性病历审查。
在24个月期间，对567名儿童进行了身体或性虐待评估。
为身体虐待和性虐待分别选择了对虐待评估至关重要的特定项目。通过将这些项目用作指标，我们比较了引入表格后虐待评估期间获得并记录的数据与引入表格之前获得的数据。使用结构化表格时更频繁出现的信息包括：儿童和成人对袭击事件的描述（对于身体虐待情况，还包括发育史）；具体性行为；受伤机制；生殖器检查的详细描述；检查结果的绘图（包括性和身体方面）；实验室检查、照片和放射学检查的记录；以及向儿童保护服务机构报告。
结构化表格显著增加了受虐儿童评估期间病历中收集和记录的信息。发现这些表格比以前使用的非结构化机构表格更有效。
