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DOCUMENTATION: Documenting the History

Include historical data and a description of the suspected abuse or neglect.

Record specific historical data:

  • The date and time of the evaluation, referral source, and the person(s) accompanying the child/adolescent to the medical site

  • The name, address, professional role, and telephone number of all individuals present during the evaluation

Record the past medical history and a review of systems:

  • Location of ongoing health care
  • Immunization history
  • Previous injuries
  • Hospitalizations
  • Specific complaints (e.g., vaginal discharge) and nonspecific complaints (e.g., behavior changes, enuresis)

In the setting of physical injury, record:

  • The specifics of the mechanism of injury (e.g., height of fall, impacting surface)
  • Time of the injury
  • Witnesses to the injury

Record a description of the suspected abuse and the name of the person giving the description.

If the child/adolescent is verbal, able to be interviewed, and has made a disclosure of abuse, record:

  • The date and time of the disclosure and the time elapsed since the abuse or injury

  • The specifics of the disclosure and to whom it was made

  • All statements made by the child/adolescent, verbatim

  • Whether the child/adolescent's statement was spontaneous; if not, what you asked to elicit the statement

  • The emotional and physical state of the child/adolescent at the time of the disclosure

  • The developmental level of the child/adolescent to facilitate assessing the credibility of the history of an injury. In the setting of suspected sexual abuse, developmentally inappropriate sexual knowledge may be compelling supportive evidence that a child has experienced an act he/she is not developmentally capable of fabricating.

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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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