Intimate Partner Violence (IPV)

Case Documentation: Other details

Record details of the event
when, where, and how the reported event happened, and who lives with the subject child(ren)
Generate a list of differentials
note any medical conditions that might mimic the abuse pattern
Relevant Past History
or a history of past injuries, hospitalizations, or ED visits
Record a follow-up plan to include
recommendations for treatment, additional medical testing, timing, and need for reassessment
Review your documentation for accuracy and completion
ensure details about the encounter are not forgotten as there may be a significant time delay between an evaluation and any legal proceedings

REFERENCES:

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

CHAMP Education for Child Abuse Medical Providers

Accessible Version

Additionally, for case documentation, it is also important to record details of the event: When, where, and how the reported event happened, and who lives with the child or children. Generate a list of differentials, note any medical conditions that may mimic the abuse pattern. Note the relevant past history or a history of past injuries, hospitalizations, or ED visits. Record a follow-up plan to include recommendations for treatment, additional medical testing, timing, and a need for reassessment. And review your documentation for accuracy and completion to ensure details about the encounter are not forgotten, as there may be significant time delay between an evaluation and any legal proceedings.