History

Every medical evaluation includes obtaining a history from the patient and family. Healthcare providers ask questions related to suspected abusive incident(s) and document the responses in the electronic medical record, including tables and checkboxes and 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 medical provider. When child maltreatment is suspected, the main goals of the medical history are to:

• Obtain information to assess possible injury or infection
• Determine the presence of possible medical symptoms that may or may not be related to the abuse
• Evaluate the child/adolescent's emotional state 
• Evaluate the child/adolescent's cognitive, developmental, language, and social levels
• Assess safety, particularly regarding potential discharge to the home environment
• Support the non-offending caregiver
• Develop a differential diagnosis for any symptoms
• Document critical information for legal purposes

When a parent or caregiver brings their child to the primary care or other medical provider with a concern about abuse, care should be taken create a space for the discussion that is out of earshot of the child. Discussing the abuse in front of the child has the potential to influence the child’s behavior and/or future disclosure.

The medical history is not an investigative interview or a forensic interview. Unless the medical professional is a trained forensic interviewer and is the one performing a forensic interview, the medical history should supplement information obtained by authorities.

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 questions and/or interrogations. 

In some circumstances, the medical history and investigative interview may be conducted together.

For further information on investigative interviewing, see U.S. Department of Justice, Office of Justice Programs Juvenile Justice Bulletin Child Forensic Interviewing: Best Practices and Child Welfare Information Gateway Forensic Interviewing: A Primer for Child Welfare Professionals. 2023.