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DOCUMENTATION: Documenting Other Information

Additional information that should be documented includes:

  • All reports or attempts to report to the State Central Register, including:

    • The name of the person making the report
    • The name of the person accepting/rejecting the report
    • The time and date of the report
    • The assigned case number

  • The name and unit of the assigned Child Protective Service worker and the name, precinct, and badge number of any police officers that become involved

    • This information may not be available if an investigation is just being initiated.

  • Referrals for ongoing medical care, mental health services, victim advocacy services, and law enforcement services

  • Discharge instructions and the caregiver's level of understanding

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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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