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DOCUMENTATION: Documenting the Diagnosis

Careful documentation of the diagnosis is particularly important because medical jargon is often misinterpreted by Child Protective Services and law enforcement authorities:

  • Do not use the term "Rule Out (R/O)" in front of the diagnoses that are being considered. It is often interpreted as meaning that the diagnosis has been ruled out.

  • Do not write "examination negative for sexual abuse" because a normal physical exam does not prove that abuse did not occur.

  • Avoid using the words "alleged" and "rape" because they have specific legal meanings. Non-medical professionals may interpret these words differently than your understanding of them.

  • In the setting of physical abuse, carefully document the reason for the conclusion that injuries were not accidental. Examples include "because of the forces required to produce such injuries, the history given does not adequately explain the child's injuries" and "the history is not consistent with the child's injuries."


Suggested Wording for Documentation of a Diagnosis
line spacer The following guidelines and examples were developed to assist in the documentation of conclusions regarding suspected child sexual abuse examinations for medical providers who are not experts in the field of child abuse pediatrics.
  1. When the medical provider has little knowledge or experience in the interpretation of the results of the medical evaluation:

    • "The history obtained reveals risk factors and indicators suspicious for sexual abuse. Interpretation of the evaluation and physical findings is deferred for later review with expert consultation."

  2. When a history of abuse is obtained from the child, the following impressions may apply:

    • "The child has given a detailed history to caregiver/parent (or medical provider) with sexual knowledge beyond his/her developmental level. The physical exam reveals acute (or healed) evidence of blunt force penetrating trauma."
        Diagnosis: Sexual abuse
          Genital injury

    • "The child has given a detailed history to caregiver/parent (or medical provider) with sexual knowledge beyond his/her developmental level. The normal physical examination is consistent with the history because any previous injury could have healed without residua due to the time frame since the incident (OR the history of sexual interaction is not anticipated to leave physical or forensic residual findings)."
        Diagnosis: Sexual abuse

  3. When the child does not give a clear, consistent disclosure to the medical provider, the following impressions may apply:

    • "The child has exhibited (or the caregiver/parent has observed) developmentally inappropriate sexual behaviors which are suspicious for sexual abuse. The physical examination reveals evidence of acute or healed blunt force penetrating trauma. These findings are often observed following sexual abuse."
        Diagnosis: Sexual abuse
          Genital injury

    • "The child has exhibited (or the caregiver/parent has observed) developmentally inappropriate sexual behaviors which are suspicious for sexual abuse. The normal physical examination neither confirms nor denies the possibility of sexual abuse (or reveals nonspecific findings consistent with another genitourinary problem)."
        Diagnosis: Behavior problem (or specific genitourinary problem)
          Suspected sexual abuse

  4. When the child is brought to the medical provider for some other reason and the physical examination findings lead to a suspicion of sexual abuse, the following statement may apply:

    • "The child was brought for evaluation for (give reason) and has not provided a history that is consistent with the physical findings. The physical findings indicate previous (or acute) genital trauma. Other findings (oral petechiae, bruises, grab marks, etc.) are present (absent). The history does not correlate with the physical findings."
        Diagnosis: Suspected sexual abuse
          Genital injury (Leave out if exam is normal.)

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Documentation: Overview  Documentation: Documenting the History  Documentation: Documenting the Findings  Documentation: Documenting the Diagnosis  Documentation: Documenting Other Information  Documentation: Photographic Documentation  Documentation: Coding for Billing  Documentation: Additional Resources 

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Suggested Wording for Documentation of a Diagnosis