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
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.