The history is that portion of the medical assessment that describes the factors related to the abusive incident(s) in a clear, chronological narrative. In addition, the medical history is a valuable aspect of the evidence collection process because the child/adolescent may more readily discuss such issues as genital pain or other genitourinary symptoms and disclose abuse to a trusted and known medical provider. The main goals of taking the medical history are to:
Obtain information to assess possible infection or trauma
Determine the presence of possible medical symptoms that may be related to the abuse
Evaluate the child/adolescent's emotional state
Evaluate the child/adolescent's cognitive, developmental, language, and social levels
Develop a differential diagnosis
Document critical information for legal purposes
The medical history is not an investigative interview and should not replace a skilled forensic interview. It should supplement information obtained by authorities.
For further information on investigative interviewing, see the New York State Children's Justice Task Force Forensic Interviewing Best Practices.
If the child/adolescent has had an investigative interview, consult with the referral source prior to taking the medical history. In addition, inquire if there are previous medical records, including ED records; previous or current Child Protective Services reports; police reports; or school nurse records. This can significantly shorten the history taking process and prevent trauma from repeated interrogations.
In some circumstances, the medical history and investigative interview may be conducted together in order to take advantage of the first contact when information is obtained and is least likely to be contaminated.