• 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, and allergies.
• Do document child’s activities that may impact forensic evidence recovery (i.e. bathing).

Review of Systems

• Do document changes in behavior, nightmares, depression etc.
• 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 findings.
• 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 sex, 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. male 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. female 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 injury.
  • 5 m.o. male 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.