ED Pathway for Evaluation/Treatment of Children with Physical Abuse Concerns
Documenting the History
- Do document clearly who is providing the history.
- Do appropriately attribute the statement to the source.
(i.e. Mrs. Jones stated that Johnny told her…)
- Do document what happened, when, and who was involved.
- Do use quotations to document exact words when a child
directly discloses to you.
- Do document any pain a child reports being associated
with the injury.
- Do document past medical history, social history, medications,
- Do document child’s activities that may impact
forensic evidence recovery (i.e. bathing).
Review of Systems
- Do document changes in behavior, nightmares, depression
- Do document any general or somatic symptoms, including
nausea or vomiting, abdominal pain, fever, etc.
Documenting the General Physical Examination
- Do document a full physical examination and any abnormal
- Do describe, draw, and photograph any injuries.
Documenting the Impression (To be completed by ED physician)
- Do provide a summary statement that includes patient’s
gender, age, and reason for evaluation, examination findings.
- Do offer an appropriate interpretation of the findings
in the context of the history such as the following:
- 4 m.o. boy who presented with seizure. Noted to have facial bruising
on examination. CT scan with acute SDH, skull fracture. Skeletal survey
with rib fractures. Multiplicity and severity of injuries extremely
concerning for inflicted trauma. Report filed with DHS and police.
- 18 m.o. girl who presented for evaluation due to refusal to walk
after a fall from standing. Right femur fracture. Injury is consistent
with developmental ability and history, and is consistent with accidental
- 5 m.o. boy with skull fracture after reportedly falling from arms
of his father 5 days ago. Child screened for occult injury due to
delay in care – no evidence of occult fractures or abdominal
trauma. History is consistent with injuries detected. Not reported
to DHS at this time due to low suspicion for inflicted trauma.