Examples of Elements Specific to Physical Abuse

(1)

0 U 0 0 U C 0 U 0 0.

U Structured Forms

ER Forms

,

, \C

,, ,4Z3 q

Common Elements

*0

11q

‘p4

.?

.

;

o

,

Common Elements

Examples

of Elements

Specific

to Physical

Abuse

ARTICLES 431

Mechanisms of Force: ____________________________ Physical Abuse Complaint Form-YES ____ NO....

Mechanisms of Force: _______________________________

Symptoms After Incident: ____________________________

Evidence Collected:

Urinalysis: YES NO Results

HMA 14: YES NO Results

Coags: YES NO Results

_____

SMA 20 YES NO Results

Radiographs:YES NO Results

SkeletalSurvey:YES NO Results.

CT Scans:YES NO Results

Physical Examination:

VS:HR: BP: RR: T: WT: %: HT: %:

General Appearance: Skin:

HEENT: Ext:

Neuro: Level of Consciousness: Cranial Nerves: _____________

Motor:

Snsnrv

DTR Tone:

Developmental Ability Demonstrated:

Examples

of Elements

Specific

to Sexual

Abuse

Sexual Acts:

Did penetration occur vaginally or rectally YES NO

DON1 KNOW______________________

Did ejaculation occur: YES NO DON’T KNOW___

Was oral sex performed on or by the child: YES NO..

DON’T KNOW________________________

GU Exam:

Presence of Blood or Semen: ________________________

Vulva, Labia Majoral Minora (inc. abrasions, adhesions ecchymoses):

Appearance of Hymen (inc. intact, absent, traumatized):

Appearance of Vagina (inc. bleeding, lacerations, foreign body, width):

Cervix:

Appearance of Penis/Scrotum: ____________________ Perineum (inc. ecchymoses, abrasions): __________________ Anus (inc. tears, bleeding, abrasions, width):_____________

Evidence Collected:

Urinalysis: YES _ NO Results ___________________

Urine Pregnancy Test: YES NO Results: _________

Urine Toxicology Screen: YES _NO Results: ________

Blood Aichohol Level YES _NO Results:

________

GC Cultures Throat: YES NO Results:___________

Rectum: YES NO Results:_________

Vagina:YES NO Results: ____________ Chiamydia Cultures Rectum: YES NO Results:____

Vagina: YES NO Results:_____

RPR: YES _ NO Results:_________________

HJV (with consent): YES NO Results: __________

Cervical Gram Stain: YES NO Results:

________

Wet PrepIKOH: YES NO Results:__________

PERK Kit Completed: YES NO Results:

________

Fig 2. Elements unique to physical abuse or sexual abuse.

Fig 3. Elements common to both physical and sexual abuse:

in-formation collected.

lected and documentation of information were found in the specific elements that were unique to either physical abuse (P < .001) or sexual abuse (P < .0001). These results are found in Tables 1 and 2.

DISCUSSION

Based on a review of the 1iterature24’2’3 and now

our own investigation of the subject, we are

con-vinced that standardized or structured clinical forms,

CPS: ChIld ProtectIve Services

. Structured Forms

ER Forms

Fig 4. Elements common to both physical and sexual abuse: in-formation documented.

particularly in a teaching setting, improve both the

quality and quantity of information collected and

documented during an encounter with a patient. The

model used was the evaluation of children suspected of being physically or sexually abused, and the prob-lems we sought to address involved the inefficient collection of important information and the ineffec-tive formatting of what information was collected.

The literature details numerous attempts to solve

at Viet Nam:AAP Sponsored on September 1, 2020 www.aappublications.org/news

(2)

TABLE 1. Elements Unique to Physical Abuse

432 USE OF STRUCTURED CLINICAL FORMS IN CHILD ABUSE

Element Recorded Emergency Unit Forms, %

Recorded Structured Child Abuse Forms, %

Developmental history” 0.7 35

Mechanism of injury” 72 95

Physical exam: skin* 73 94

Physical exam: neurologic* 26 95

Laboratory studies* 6 91

Radiologic studies* 19 93

*P < .001.

TABLE 2. Elements Unique to Sexual Abuse

Element Recorded Emergency Unit Forms, %

Recorded Structured Child

Abuse Forms, %

Sexual acts: penetration* 23 91

Sexual acts: ejaculation* 12 90

Sexual acts: oral sex* I I 90

Physical exam: blood or semen* 23 97

Physical exam: vulva/labia* 4f, 98

Physical exam: hymen* 51 97

Physical exam: vagina* 47 80

Physical exam: vaginal width* 42 77

Physical exam: penis/scrotum* 18 93

Physical exam: perineum* 18 93

Physical exam: anus* 62 96

Laboratory studies: GC cultures (any site)* 50 98

Laboratory studies: chlamydia cx (any site)* 53 98

Laboratory studies: forensic evidence* fl 97

*P < .0001.

these problems. Christopher et a! postulated that

providing intensive educational programs to a spe-cific group of residents would improve the quality of documentation of an injury or abuse event. Others

have reported that completion of specifically

de-signed child abuse education programs significantly increased knowledge and case recognition skills.1416

Traditional education in this area has focused on

improved case finding through enhancement of the

physician’s ability to recognize signs and symptoms

that suggest abuse and on the reporting of these

findings.17 Unfortunately, follow-up assessments show a lack of retention of this new knowledge.18

At our institution, education about the evaluation

of children suspected of being abused has been

ex-tensive. Residents were, on an on-going basis, edu-cated with respect to the recognition, diagnosis, and

treatment of these children. They were taught to

perform an abuse evaluation and seemed to

under-stand the importance of documentation. This educa-tion was provided in large lecture, small group, and

individualized sessions throughout the 3 years of

pediatric training. In addition, rising second-year residents participated in an annual 4-hour seminar

on the evaluation of children suspected of being

sexually abused, because it is the expectation of the program that they will be the primary evaluators of these children. Nothing in our education program changed during the transition from the institutional evaluation forms.

Despite this education, the active involvement of our large, multidisciplinary team, individual sup-port, and interdisciplinary conferences, the residents

continued to describe feelings of insecurity in the performance of an abuse evaluation. The quantity of

information required to be collected and

docu-mented was thought to be overwhelming and was

generally perceived as being outside the medical

model. In addition, many of the evaluations of this

sort occurred in high-volume, quick-paced,

high-pressure environments where little guidance was

provided, yet focused evaluations were expected.

Our structured forms provided that focus for the

user and a consistent method for collecting medical, social, and legally required data.

We think that the reason the forms worked was

that they were specifically designed for their

in-tended purpose: to facilitate the collection and doc-umentation of information. In our system, each

sec-tion had prompts detailing for the physician the

specific information to be obtained. Prompts also

encouraged the documentation of information

col-lected (eg, checklists to order tests and preprinted

anatomic drawings on which to record objective

findings suggesting intentional injury). Finally, the user was directed to the development of an assess-ment and plan, as well as to a protocol for reporting

the alleged abuse. The completed forms were then

available to provide information to other medical providers, Child Protective Services, law enforce-ment officials, and the courts to assist in their hives-tigations of reported cases.

Since their introduction, we have noted a positive response from our residents to the use of structured forms. Anecdotally, they report that they are more comfortable in the assessment of these children and

(3)

ARTICLES 433

have indicated to us a decrease in their anxiety about potentially disregarding or not including important

information. This may have some impact on their

future practices as managed care organizations

be-come more insistent on primary care physicians

pro-viding comprehensive care to their groups of

pa-tients. Further study in this area is warranted.

The structured form also served as a teaching tool,

an important consideration, because our role as an

academic medical center is not only to provide

pa-tient care, but also to teach others to provide that care. In practice, each evaluation was reviewed with the resident who performed it. Specific comments on

the evaluation and documentation were made

mdi-vidually. In addition, sending copies of the evalua-tion to the referring physician or agency extended

the education process beyond the institution.

Al-though this area certainly deserves further

investiga-tion, we have observed thus far that those who

re-ceived the completed evaluations have become

increasingly comfortable with their own interactions with abused children.

CONCLUSION

Based on our results, we think that this model of a specifically designed, structured form might also be applicable in other clinical situations in which the complete and accurate recording of medical informa-tion is often critical. Acute injuries not caused by

abuse, asthma, and other conditions might well be

amenable to this approach to evaluation, diagnosis,

and treatment. In our study, we have shown that by

listing all the information required for the evaluation of abused and neglected children, pediatric residents

provided more complete medical records in these

evaluations. Structured forms, therefore, may be de-signed to accommodate multiple clinical situations and to increase the quality and quantity of informa-tion collected and recorded in various settings.

ACKNOWLEDGMENT

This research was supported by a grant from the Virginia Department of Social Services.

REFERENCES

1.Christopher NC, Anderson D, Gaertner L, Roberts D, Wasser TE. Child-hood injuries and the importance of documentation in the emergency department. Pediatr Ernerg Care. 1995;1 I :52-57

2. Wallace SA, Gullan RW, Byrne P0, Bennett J, Perez-Avila CA. Use of a pro forma for head injuries in the accident and emergency department: the way forward. IAccid Ernerg Med. 1994;1 I :33-42

3. Leslie KO, Rosai J. Standardization of the surgical pathology report: for-mats, templates, and synoptic reports. Semin Diagn Pathol. 1994;11:253-257 4. Casserly HB, Tomas P. Updating the accident and emergency record.

Injury. 1992;23:174-1 76

5. Woolf A, Taylor L, Melnicoe L, et a!. What residents know about child abuse: implications of a survey of knowledge and attitudes. Am IDis Child. 1988;142:668-672

6. Solomons G. Trauma and child abuse. Am JDis Child. 1980;134:503-505

7. Orr DP. Limitations of emergency room evaluations of sexually abused children. Am IDis Child. 1978;132:873-875

8. Orr DP, Prietto SV. Emergency management of sexually abused chil-dren. Am IDis Child. 1979;133:628-631

9. Dubowitz H, Bross DC. The pediatrician’s documentation of child mal-treatment. Am JDis Child. 1992;146:596-599

10. Newberger EH. Pediatric interview assessment of child abuse: chal-lenges and opportunities. Pediatr Clin North Am. 1990;37:943-954 11. DeJong AR, Finkel MA. Sexual abuse of children. Curr Probl Pediafr.

1990;20:495-567

12. American Medical Association. Diagnostic and Treatment Guidelines on

Child Sexual Abuse. Chicago, IL: American Medical Association; 1992

13. American Medical Association. Diagnostic and Treatment Guidelines on

Child Physical Abuse. Chicago, IL: American Medical Association; 1992

14. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children.

Pediatrics. 1991;87:254-260

15. Grant U. Assessment of child sexual abuse: eighteen months’ experience at the child protection center. Am IObestet Gynecol. 1984;148:617-620

16. Showers J, Laird M. Improving knowledge of emergency physicians about child physical and sexual abuse. Pediatr Emerg Care. 1991;7: 275-277

17. Alexander RC. Education of the physician in child abuse. Pediatr Clin North Am. 1990;37:971-988

18. Naureckas SM, Christoffel KK. Improving pediatric intern’s injury histories: habits are hard to change. Pediatr Emerg Care. 1992;8:305. Abstract

(4)

1996;98;431

Pediatrics