Documentation of child physical abuse: how far have we come?

OBJECTIVES

To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse.

DESIGN

Retrospective chart review.

PARTICIPANTS

Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse.

MEASUREMENTS

The unstructured pediatric emergency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995.

RESULTS

The only significant differences between 1980 and 1995 concerning documentation on the unstructured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were obtained in 1995, although notation of the results was similar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency department and illustrations of injuries.

CONCLUSIONS

Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.