Documentation of Child Physical Abuse: How Far Have We Come?
Mary Ann P. Limbos, MD, MPH*‡ and Carol D. Berkowitz, MD*
ABSTRACT. Objectives. To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse.
Design. Retrospective chart review.
Participants. Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse.
Measurements. The unstructured pediatric emer-gency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995.
Results. The only significant differences between 1980 and 1995 concerning documentation on the unstruc-tured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were ob-tained in 1995, although notation of the results was sim-ilar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency depart-ment and illustrations of injuries.
Conclusions. Little improvement in physician docu-mentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate house-staff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items. Pediatrics 1998; 102:53–58;child abuse, physical abuse, documentation.
D
uring the past decade, a growing body of medical literature has described physical and behavioral findings suggestive of child abuse. In addition, most general pediatric textbooks now include chapters on child maltreatment, andpediatric and emergency medicine residency pro-grams provide specific training in its recognition. It is unclear, however, whether this increased aware-ness and education of physicians have resulted in more precise and complete medical documentation. Thorough documentation in cases of suspected child abuse is extremely important because the med-ical record is a legal document and is routinely used by public agencies when investigating reports and making placement decisions.1 Furthermore, a clear and comprehensive medical record may avert the need for a physician’s testimony in civil cases or in juvenile court.2If court testimony is necessary, well-documented medical records provide evidence, re-fresh the physician’s memory, and may reduce the time spent in judicial proceedings.3A 1980 study of young children evaluated for traumatic injuries in a teaching hospital defined an adequate medical record as meeting four criteria: 1) history of the in-jury; 2) description of the inin-jury; 3) documentation of previous injuries or accidents; and 4) compatibility or incompatibility between the history given and the injuries sustained.4Based on these criteria, the study revealed that 60% of the 156 records had inadequate data to determine retrospectively if child abuse had occurred or whether the diagnosis had been consid-ered by the evaluator. The criteria for a complete medical record have since been expanded to include documentation of the developmental history, sup-plemental illustrations and/or photographs of phys-ical findings, procedures performed, a diagnosis, and final disposition of the child.1Such important details can be easily overlooked, especially in busy emer-gency departments where children with suspected abuse are often first evaluated. In addition, there may be limited space for a private interview with the child and caretakers, and although the physical ex-amination may be thorough, the findings may not be clearly, completely, or legibly documented.
We sought to determine whether physician docu-mentation of suspected child physical abuse has changed at our institution between 1980 and 1995. To assess this, we reviewed the emergency department records of children evaluated for physical abuse in 1980 and 1995 at Harbor-UCLA Medical Center, a county hospital, to: 1) evaluate the completeness of medical documentation for each year; 2) determine whether an interval improvement in documentation occurred between 1980 and 1995; and 3) examine the effect of a structured form on the completeness of documentation. In our hospital, physicians evaluat-ing a child for suspected abuse complete both a relatively unstructured emergency department
nar-From the *Division of General and Emergency Pediatrics, Harbor-UCLA Medical Center, Torrance, California; and currently in the ‡Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, Califor-nia.
Presented in part at the Region IX and X Meeting of the Ambulatory Pediatric Association, Carmel, California, on February 9, 1997 and at the annual meeting of the Ambulatory Pediatric Association, Washington, DC, May 2, 1997.
Received for publication Sep 29, 1997; accepted Jan 6, 1998.
rative form and a structured form required by the California Department of Justice. The latter is a two-page form providing spaces for past and present historical information, diagnostic procedures and their results, and case disposition, as well as a figure for illustrating physical findings. Both forms were unchanged between 1980 and 1995.
We specifically studied children with the dis-charge diagnosis of physical abuse. We chose to com-pare 1995 to 1980 because the interval of 15 years not only corresponded to a time of increasing general public awareness of child abuse but also to a time in our hospital which witnessed the formation of a Suspected Child Abuse and Neglect team (1980) and the creation of a Child Crisis Center (1982). In addi-tion, required half-day abuse workshops and a child abuse elective of 2 to 4 week’s duration were intro-duced into the residency curriculum in 1985. We hypothesized that documentation would be more meticulous in cases in which abuse was suspected and that a structured form would provide more com-plete documentation than an unstructured form.
METHODS
The Harbor-UCLA Pediatric Emergency Department log books were reviewed for children given the discharge diagnosis of “child abuse” or “nonaccidental/intentional trauma” between January 1, 1980 to December 31, 1980 and between January 1, 1995 to De-cember 31, 1995. Children with the diagnosis of “child neglect” or “sexual abuse” were excluded from the study. Children given the discharge diagnosis of “child abuse” but whose medical chart revealed that they had undergone evaluation for sexual abuse were also excluded. The emergency department record was re-viewed for notation of the following:
1. Historical items: time of arrival to the emergency department, accompanying adult (parent, law enforcement, etc.), age of child, time of alleged injury (general; ie, yesterday; or specific time), nature of injury (fall, burn, etc.), witnesses to injury, history of past injuries, and developmental history.
2. Physical examination items: description of location, size, and/or color of any physical injuries, drawing of injuries, and photographs taken.
3. Supplemental diagnostic procedures: skeletal survey and labo-ratory tests (hemoglobin/hematocrit, prothrombin time, and partial thromboplastin time).
4. Diagnosis: specific wording of the diagnostic impression, in-cluding use of terminology such as “rule out abuse,” “proba-ble/suspected abuse,” and “history of abuse”; and a descriptive summary of physical findings.
5. Disposition: Department of Children and Family Services and/or law enforcement involvement, and final disposition of the child.
Data were analyzed using Epi Info (Centers for Disease Control and Prevention, Atlanta, GA) software. Student’sttest, Fisher’s exact test, and the x2test were used for statistical analysis. The level of statistical significance was chosen to be P ,.05 (two-sided).
RESULTS Sample Characteristics
Of 25 500 children evaluated in the emergency department in 1980, 64 children were given the dis-charge diagnosis of “child abuse” or “nonaccidental/ intentional trauma.” Fifty-three (81%) of these med-ical charts were available for review; 9 were cases of sexual abuse and were subsequently excluded from the study, leaving 44 eligible medical records. Forty of the 44 (91%) children had alleged physical abuse.
Of the remaining 4 children, 1 had behavioral prob-lems and was referred for an abuse evaluation with-out a specified injury, 1 was felt to be malnourished and given the diagnosis of “rule out child abuse,” and 2 children were siblings of fatal child abuse victims and were also given the diagnosis of “rule out child abuse.”
Thirty-one of the 25 470 children evaluated in the emergency department in 1995 were given the diag-nosis of child physical abuse and 29 (94%) of these records were available for review. Twenty-five of the 29 (86%) children had alleged physical abuse and 4 (14%) presented with behavioral changes.
The sample characteristics for each year are pre-sented in Table 1. Twenty-six percent of the children evaluated in 1995 were 11 years or older; this age group accounted for only 7% of the total in 1980. However, a comparison of the mean ages of the children in each year shows no significant difference (P5 .10). The most commonly-represented age cat-egory in both years is the 1- to 5-year-old age group. Approximately half of children in 1980 and 1995 with alleged physical abuse had a history of having been beaten, most commonly with an adult hand/fist or belt. Other children had unexplained bruises, burns, fractures, and behavioral changes.
Documentation of Specific Items
The proportion of medical records documenting each of 20 items is presented in Table 2.
Historical Items
There was little difference between 1995 and 1980 in the documentation of historical items. Although the injury or the reason prompting evaluation for abuse and the identity of the accompanying adult were consistently noted in 1980 and 1995, both years also showed a consistent lack of documentation of witnesses to the injury. More than three fourths of charts in each year had no mention of witnesses to an alleged injury. Although the time of the alleged
in-TABLE 1. Sample Characteristics
1980 1995
Cases identified 55 31
Records available 44 (80%) 29 (94%) Age of child
,12 mo 18% 13%
1–5 y 48% 42%
6–10 y 27% 16%
.10 y 7% 26%
Mean age* (mo) 59.7 77.7 Presenting complaint
Beaten with object 27% 45% Beaten, unspecified 20% 7%
Bruises 25% 10%
Fracture 5% 7%
Burn 14% 3%
Behavior change 0% 14%
Other 8% 14%
Physical findings present 84% 72% Diagnoses
Probable/suspected abuse 43% 76% Rule out child abuse 43% 17% Nonaccidental/inflicted trauma 14% 7%
jury was fairly well documented in both years, fewer than half (41%) of the records in 1995 documented the time of arrival to the emergency department compared with 70% of the 1980 records (P 5 .02). Whereas 59% of the records in 1980 remarked on a past history of injuries, only 45% of 1995 charts did so; this difference was not statistically significant. Notably, none of the 72 medical records from either year documented a developmental history.
Physical Examination Items
Physical findings were documented in 84% and 72% of the medical charts for 1980 and 1995, respec-tively. Although the location of such physical injuries was documented in every record for both years, fur-ther description of these injuries by size and color was less complete. Just slightly more than one third of charts in 1980 provided a description of size and/or color of any physical injuries. This propor-tion rose to .50% in 1995; however, this was not a statistically significant increase (size, P5 .23; color,
P 5 .13). Although fewer than 20% of records for either year provided an accompanying illustration in cases in which a physical injury was documented, four photographs were noted in 1995 compared with none in 1980. Only half of the medical records from either year documented a genital examination.
The age of the child had little effect on documen-tation of physical examination items in either year
(Table 3). In both 1980 and 1995, records of children ,5 years of age were as likely to be missing docu-mentation of a genital examination as were records of children 5 years of age or older. In those children with physical findings, younger children did not have more complete documentation of their physical injuries compared with older children.
Supplemental Diagnostic Procedures
Although there was no difference in the frequency of laboratory tests documented in each year, there was a significant difference in the documentation of the skeletal survey. Although a skeletal survey was noted for .80% of the children evaluated in 1980, only 38% of the children evaluated in 1995 had a documented skeletal survey (P5 .0002). The differ-ence between the years is evident in both younger and older children: children,5 years of age as well as those 5 years of age or greater were more likely to have a documented skeletal survey in 1980 than in 1995 (Table 3). The mean age of children with a documented skeletal survey was 5 years (range, 4 months to 15 years 7 months) in 1980; 57% of the children were ,5 years old. The mean age of chil-dren with a documented skeletal survey in 1995 was 3.9 years (range, 4 months to 12 years 6 months) with 73% of these children being,5 years old. The differ-ence in the mean ages was not statistically significant (P5.25).
Diagnoses
The most frequent written diagnoses in 1980 were “rule out child abuse” (43%) and “suspected/proba-ble child abuse” (43%). The remaining 14% of the records had the diagnosis of “nonaccidental/inten-tional trauma.” In comparison, only 17% and 7% of the 1995 records had the diagnosis of “rule out child abuse” and “nonaccidental/inflicted trauma,” re-spectively. “History of abuse” and “probable/sus-pected abuse” accounted for greater than 75% of the written discharge diagnoses in 1995. Forty-five per-cent of the diagnoses in 1995 and 36% of those in 1980 were followed by a descriptive summary of physical findings such as “bruises of multiple ages.”
Disposition
Medical records from 1995 were more likely to document a discharge plan than were records from 1980. Although every emergency department chart reviewed from 1995 noted whether there had been Child Protective Services and/or law enforcement involvement, only 77% of the 1980 charts did so (P5
.004). Furthermore, 90% of records from 1995
docu-TABLE 2. Documentation of Specific Items
Documentation of: 1980, % 1995, % P*
Age 98 100
Accompanying adult 86 93
Time of arrival 70 41 .014
Time of injury 58 72
Type of injury 98 100
History of past injuries 59 45 Witnesses to injury 22 16 Developmental history 0 0 Description of injuries
Location 100 100
Size 38 62
Color 35 57
Genital exam 52 55
Drawings of findings 16 19
Photographs 0 19
Radiographs
Taken 84 38 ,.001
Results 84 100
Lab tests
Taken 61 38
Results 85 100
Child Protective Services involvement 77 100 .005 Disposition of case 66 90 .02
*Pvalues are indicated only if,.05.
TABLE 3. Effect of Age on Documentation of Physical Examination Items and the Skeletal Survey
Documentation of: 1980 P 1995 P
,5 Years Old 5 Years or Older ,5 Years Old 5 Years or Older Description of injuries
Location 100% 100% – 100% 100% –
Size 30% 50% .24 70% 54% .66
Color 30% 43% .49 80% 45% .18
Genital exam 52% 53% .94 60% 50% .59
mented the child’s disposition compared with only 67% of records from 1980 (P5 .03).
Unstructured Versus Structured Forms
For both years, use of the structured form im-proved documentation of only two items: the time of arrival to the emergency department and drawings of injuries (Table 4). In 1980, 19% of the unstructured forms had a diagram of injuries compared with 97% of the structured forms. There was a similar increase in 1995 from 31% to 100%. There was no significant improvement of documentation of the remaining 18 items with use of the structured form.
DISCUSSION
Since Kempe’s5 initial description of the battered child syndrome in 1962, the recognition and evalua-tion of child abuse have become necessary skills for medical personnel caring for children. Although pe-diatric and emergency medicine residency programs provide training in these skills through didactic lec-tures and workshops, an often overlooked but essen-tial skill is the accurate and thorough recording of the medical evaluation. In 1980, Solomons’4review of hospital charts of young children with traumatic in-juries found that the majority of records contained inadequate data to determine retrospectively if the diagnosis of child abuse had ever been considered by the evaluator. He states that “it is possible that the appropriate questions were asked and satisfactory answers were given, but they were not recorded.” We sought to determine at our institution if the questions and answers were more completely re-corded in 1995 than they were in 1980. Furthermore, are the physical examination, diagnostic procedures, assessment, and disposition better documented in 1995 compared with 1980?
To investigate these questions, we focused specif-ically on cases of suspected physical abuse evaluated in our emergency department. In circumstances when the diagnosis is child abuse, omissions and inaccuracies in the medical record are critical when legal decisions must be made. From our review, we conclude that most aspects of emergency department documentation in cases of suspected child physical abuse have changed little between 1980 and 1995. Although there have been interval improvements in the documentation of the plan and disposition, there continue to be omissions of important historical and physical examination items. First, a developmental history was missing from every record reviewed. Although not as crucial in older children, a develop-mental history in an infant or young toddler can provide valuable information. For example,
knowl-edge of the child’s gross motor abilities can help assess whether a history of climbing out of the crib is plausible.1Other historical items of information that help determine the reliability of a given history are the presence of witnesses to injury, the time elapsed between the injury and the emergency department visit, and a history of past injuries.6All were incon-sistently documented in both 1980 and 1995. Docu-mentation of even negative information such as “there were no witnesses to the injury” or “there is no history of past injuries” is relevant and can be helpful in assessing the history provided.
There also seemed to be little improvement in the documentation of the physical examination between 1980 and 1995. Although an evaluation for abuse should include a complete physical examination, in-cluding examination of the genitalia,7 only half of children in each year had a documented genital ex-amination. Furthermore, we were unable to show a significant increase in the number of medical records containing detailed descriptions and sketches of physical injuries. Photographs were uncommon in either year although four were documented in 1995. Without photographs or a clear diagram, a judge or jury may not be able to fully appreciate the extent of injuries despite a detailed description.1,8,9
Radiologic skeletal surveys were obtained signifi-cantly less often in 1995 compared with 1980. Al-though the mean age of children with a documented skeletal survey did not differ significantly between the 2 years, a greater proportion of children in 1995 were,5 years of age. A probable explanation is the changing policy of obtaining skeletal radiographs in cases of suspected abuse. Obtained more often as part of the evaluation for abuse in 1980, skeletal radiographs are now obtained routinely only when evaluating the young (,2 years of age), preverbal child.10 Otherwise, radiographs are performed as part of the child abuse evaluation only when there is a specific indication such as a swollen, tender ex-tremity.
Areas of documentation that improved between 1980 and 1995 were the diagnosis and disposition of the child and public agency involvement. Since the late 1980’s, housestaff have been advised to replace the equivocal phrase “rule out child abuse” with more definitive statements of “probable/suspected physical abuse” or “history of abuse” followed by a descriptive summary of findings. This teaching is evident in the different discharge diagnoses written in 1980 compared with those in 1995. Although “his-tory of abuse” by itself may be nebulous, it can be strengthened by an assessment of whether the phys-ical findings are consistent or inconsistent with the history, and may be a reasonable statement if the physician is unsure of the diagnostic significance of the physical findings. The increased interactions among law enforcement, Child Protective Services, and the evaluating physician are also reflected in the documentation: every medical record in 1995 noted the involvement of police and social services com-pared with 77% of records in 1980.
Recent articles have suggested that a standardized clinical form may be helpful in improving
documen-TABLE 4. Unstructured Versus Structured Forms
Documentation of: Unstructured Structured P
Time of arrival
1980 72% 97% .003
1995 39% 89% .002
Drawings of findings
1980 19% 97% ,.001
tation. In Bar-on and Zanga’s31996 study, the use of a structured clinical form significantly increased the information collected and documented in evalua-tions of both physically and sexually abused chil-dren. Furthermore, the authors noted an added benefit: residents felt more comfortable in the assess-ment of abused children and had less anxiety about potentially disregarding or not including important information. Our findings suggest that whereas a structured form greatly improves documentation of selected items such as illustrations of injuries, it does not guarantee complete documentation. These differ-ences in our findings may reflect the differdiffer-ences in the structured forms that were evaluated or the hos-pital settings in which the forms were used.
One of the limitations of our study is the small number of patients, particularly in 1995. It is possible that we were unable to show a difference in docu-mentation between the 2 years because of our sample size. Among the possible reasons for the decreased number of cases in 1995 is that children with sus-pected abuse were going to other facilities for eval-uation. Primarily a referral center for sexual abuse, the hospital’s Child Crisis Center began evaluating children with suspected physical abuse in the late 1980’s. In addition, a member of our faculty with expertise in child abuse began evaluating referrals from law enforcement and community agencies in a medical group setting rather than in the emergency department. Another possibility for the decreased diagnoses of child abuse in 1995 is the increasing use of descriptive phrases such as “5-month-old infant with blunt head trauma and retinal hemorrhages” without an explicit statement of child abuse. Such medical records would not have been included in our study although these children would clearly have undergone an evaluation for abuse. We limited our study to children with the discharge diagnosis of abuse. Had we also studied the medical records of young children with blunt head trauma or long bone fractures, we might have observed a different pattern of documentation. However, one of our major objec-tives was to focus on documentation in those partic-ular cases when the suspicion of child abuse was explicitly stated in the diagnosis and to observe how this index of suspicion was reflected in the medical record. As demonstrated by Solomons’4study, such cases are difficult to determine retrospectively.
Another limitation of our study is our inability to determine at the individual resident level the extent of participation in the child abuse educational activ-ities, leading to possible bias. For example, were the poorly documented records completed by residents who were or were not involved in child abuse ing? Furthermore, we did not include level of train-ing or specialty department (pediatrics, emergency medicine, or family medicine) in our analysis. Such variables may influence the completeness of docu-mentation.
Despite these limitations, the deficits in our cur-rent emergency department medical records are ev-ident. How can our increasing knowledge of child physical abuse be translated into a clearer and more complete medical record? First, education and
train-ing can focus on areas of the history and physical examination that are consistently poorly docu-mented. For example, training in medical documen-tation can be incorporated into the already existing child abuse workshops, child abuse electives, and emergency department rotations. One project in Ohio using self-instructional programs to improve physician training in child abuse found increases in both physician knowledge and case recognition after use of the program.11Another educational interven-tion consisting of a month-long child maltreatment course taught to small groups of residents also found short-term increases in clinical knowledge; however, residents failed to retain this knowledge several months after course completion.12 These findings suggest that any educational efforts must be ongo-ing. This can be especially challenging in the emer-gency department where there are physicians of many different backgrounds and levels of training, staff may be present on a temporary or rotating basis, and schedules often exclude housestaff on certain shifts from educational sessions.13Innovative teach-ing strategies such as interactive computer programs or videos may be promising options to address these needs.
In addition, our findings suggest changes in emer-gency department procedures and paperwork that may further improve medical documentation. Small additions in the emergency department can lead to significant improvements in documentation. A sim-ple checklist can remind medical staff about what should be documented in the medical record in cases of suspected abuse. In addition, an easily-completed structured form may also prove valuable. In the fu-ture, these forms will likely be computerized and accessible to various public agencies. A camera should be readily available in the emergency depart-ment and physicians should have a fundadepart-mental understanding of camera operation, picture compo-sition, and medicolegal implications.14Lastly, teach-ing rounds in the emergency department might be used to discuss errors, omissions, or ambiguities identified in actual records.15 Record review by fac-ulty members is an excellent opportunity to educate housestaff, and residents should be encouraged to discuss records with the attending physician.
Optimally, each emergency department that eval-uates children with suspected abuse should have a special child abuse and neglect team available to perform examinations or consultations and arrange for follow-up. Although this is not practical in many institutions, each emergency department should be aware of referral centers where comprehensive, mul-tidisciplinary evaluations for child abuse can be per-formed.
Implications
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4. Solomons G. Trauma and child abuse.Am J Dis Child. 1980;134:503–505 5. Kempe CH, Silverman FN, Steele BF, Droegmueller W, Silver HK. The
battered child syndrome.JAMA. 1962;81:17–24
6. Hammond J, Perez-Stable A, Ward CG. Predictive value of historical and physical characteristics for the diagnosis of child abuse.South Med J. 1991;84:166 –168
7. Jenny C.Medical Evaluation of Physically and Sexually Abused Children. Thousand Oaks, CA: Sage Publications; 1996
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9. Ricci LR. Photographing the physically abused child.Am J Dis Child. 1991;145:275–281
10. American Academy of Pediatrics, Section on Radiology. Diagnostic imaging of child abuse.Pediatrics. 1991;87:262–264
11. Showers J, Laird M. Improving knowledge of emergency physicians about child physical and sexual abuse. Pediatr Emerg Care. 1991;7: 275–277
12. Dubowitz H, Black M. Teaching pediatric residents about child mal-treatment.J Dev Behav Pediatr. 1991;12:305–307
13. Christopher NC, Anderson D, Gaertner L, Roberts D, Wasser TE. Child-hood injuries and the importance of documentation in the emergency department.Pediatr Emerg Care. 1995;11:52–57
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DOI: 10.1542/peds.102.1.53
1998;102;53
Pediatrics
Mary Ann P. Limbos and Carol D. Berkowitz
Documentation of Child Physical Abuse: How Far Have We Come?
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DOI: 10.1542/peds.102.1.53
1998;102;53
Pediatrics
Mary Ann P. Limbos and Carol D. Berkowitz
Documentation of Child Physical Abuse: How Far Have We Come?
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