Documenting

History

record what the child said in their own words, and whether the disclosure was spontaneous or in response to what specific question
interview the parent(s) separately and record their explanation, including any discrepancies in the history
record what happened, when, where, and how – any witnesses?
who lives with the child/takes care of the child?
note history of past injuries, hospitalizations or ED visits
note medical conditions which might mimic abuse pattern

Physical

note the physical and emotional state of the child when disclosing
note hygiene, state and appropriateness of clothing
perform a complete physical exam, including growth measurements and observation of all skin surfaces, scalp, groin, oral cavity and fundoscopic exam, with detailed documentation of any suspicious areas
if sexual abuse is suspected, do not perform a genital exam except for cursory visual inspection, as it may negate subsequent forensic exam evidence collection
pictures can be very helpful - see “Evidence” section of domestic abuse website for instructions, and/or use a body map

Lab/Radiology

record all laboratory and radiological tests ordered - consider
- ophthalmology exam in child <3
- skeletal survey in child <2
- CT scan in child <6 months

Assessment

document reasoning why injury appears to be non-accidental
do not place r/o before diagnosis, as it may be interpreted that the diagnosis has been ruled out

Plan

document who made the verbal and written report, when and to whom, and the name and/or badge number of CPS or police involved
document referrals made for other services, such as counseling
document information given to non-abusive parent, including medical care instructions
document disposition of child
follow up appointment