Intimate Partner Violence (IPV)

Case Documentation: EMR

  • Documentation of child abuse cases is not only essential for accurately diagnosing and treating patients, but for facilitating peer review, investigations, and court procedures.
  • When documenting child abuse cases, you should:
    • Record the child's words using quotes when writing about key aspects of their history
    • Interview the parents with attention to explanations noting any discrepancies in the history
    • Clearly describe all injuries (i.e., the color, size, and location of bruises)
      • Photograph injuries or draw illustrations utilizing body diagrams

REFERENCES:

  • Ornstein 2013
  • Moles et al 2021
  • Jackson et al 2006

CHAMP Education for Child Abuse Medical Providers

Accessible Version

The medical record is a legal document. So, documentation of child abuse cases is not only essential for accurately diagnosing and treating patients, but for facilitating peer review investigations and court procedures. When documenting child abuse cases, you should record the child's words using quotes when writing about key aspects of their history. Interview the parents with attention to explanations, noting any discrepancies in the history. Clearly describe all the injuries, such as the color, size, and location of bruises. And if there's a use of the photographs, please include injuries or draw illustrations utilizing body diagrams to clarify your findings.