• 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


  • 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



  • record all laboratory and radiological tests ordered - consider

    • ophthalmology exam in child <3
    • skeletal survey in child <2
    • CT scan in child <6 months


  • 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


  • 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