Trauma and child abuse. The importance of the medical record.
A chart audit was undertaken to ascertain the content and quality of documented information present in medical records of patients with traumatic injuries seen in a tertiary care hospital. Of the records of children younger than 6 years of age with a diagnosis of fracture, burn, contusion, or intracranial injury seen in the inpatient or outpatient services during a one-year period, 60% contained inadequate data on which to determine retrospectively if the medical diagnosis of child abuse was ever considered. The medicolegal implications of this are discussed.
D002649:Child Abuse; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008487:Medical History Taking; D014947:Wounds and Injuries / Q000209:etiology*