Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department.
OBJECTIVE
The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI.


METHODS
A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI.


RESULTS
Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0-3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases.


CONCLUSIONS
In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI.
Tingberg
Björn
B
Astrid Lindgren Children's Hospital, Karolinska Institutet, Department of Woman and Child Health, Stockholm, Sweden. bjorn.tingberg@karolinska.se
Falk
Ann-Charlotte
AC
Flodmark
Olof
O
Ygge
Britt-Marie
BM
D002649:Child Abuse / Q000175:diagnosis*; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging / Q000209:etiology*; D004636:Emergency Service, Hospital; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008499:Medical Records; D011859:Radiography; D012189:Retrospective Studies