Sample child abuse documentation form

1. Specifics regarding injury mechanism:
   1. When a particular fall or other injurious event occurred;
   2. Where the incident occurred;
   3. Whether it was witnessed or not;
   4. Positioning of the child when found by caregiver;
   5. Fall surface and estimated height;
   6. Medical symptoms of the child preceding and immediately after an event (ie, presence or absence of apnea, seizures, respiratory change, altered mental status, swelling, bruising, skin denudation, etc);
   7. Any history of prior trauma (in the prior weeks to months, as applicable);
   8. Any discrepancies between histories provided to different health-care professionals. If differing histories have been provided, the different versions should be documented, including information regarding who provided which version, and to whom.
      
      
       
2. Father's interview:

Father was interviewed independently and privately in __________ ...
(within reason, a caregiver's words, in quotes, should be used as much as possible, with appropriate attribution)


 

3. Mother's interview:

Mother was interviewed independently and privately in __________ ...
(within reason, a caregiver's words, in quotes, should be used as much as possible, with appropriate attribution)


 

1. Maternal:
   
   
    
2. Paternal:
   
   
    

1. Describe your child's family and living environment. Who lives in the home with your child and what are their relationships to your child?
   
   
    
2. Are you and your partner the biological parents of your child? How long have you been a couple? Do you or your partner have any other children outside of your relationship?
   
   
    
3. Who is the primary caregiver for your child? What are the care giving hours? Does your child receive child care outside of your home?
   Risk factors:
   1. Does anyone who provides care for your child use substances and/or abuse alcohol?
   2. Does anyone who provides care for your child have any mental health issues such as depression, bipolar and/or anger management issues? Has anyone ever been on medications or hospitalized?
   3. Has anyone who provides care for your child been involved with law enforcement? Has anyone ever belonged to a gang or engaged in criminal activity?
   4. How do the people providing care for your child resolve disagreements or arguments as an adult? Have you ever been hit, pushed, slapped, choked, or verbally threatening by a partner?
   5. Has any caregiver for the child been the subject of a prior child protective services investigation? If so, can you tell me a little about that?
      
      
       
4. Attachment observations:
   
   
    
5. Attributions: (describe, in three one-word adjectives [ie, "happy", "fussy", "inconsolable", etc], your baby/child)
   
   
    

1. Constitutional:
    
2. HEENT:
    
3. CV:
    
4. Respiratory:
    
5. GI:
    
6. GU:
    
7. Musculoskeletal:
    
8. Dermatologic:
    
9. Neurological:
    
10. Allergic/Immunologic:
     

1. Vitals:
    
2. General:
    
3. HEENT: (including ophthalmology examination, when appropriate)
    
4. Neck:
    
5. Heart/CV:
    
6. Lungs/chest:
    
7. Abdomen:
    
8. Extremities/muscle:
    
9. Skin: (refer to photodocumentation also)
    
10. GU:
     
11. Neurological:
     

1. PT/PTT/INR:
    
2. CBC:
    
3. CMP:
    
4. Head CT: (when appropriate - personally reviewed with pediatric neuroradiology)
    
5. MR brain: (when appropriate - personally reviewed with pediatric neuroradiology)
    
6. MR spine: (when appropriate - personally reviewed with pediatric neuroradiology)
    
7. MRA/V head and neck: (when appropriate - personally reviewed with pediatric neuroradiology)
    
8. Skeletal survey: (personally reviewed with pediatric radiology)
    

1. Level of concern for abuse: (state basis)
   1. High concern;
   2. Low concern;
   3. Indeterminate, but with significant psychosocial or other historical factors warranting report/further investigation; or
   4. Indeterminate with no other significant concerns.
      
      
       
2. Level of diagnostic confidence for abuse: (state basis)
   1. High probability of abuse;
   2. Probable abuse;
   3. Indeterminate;
   4. Probable accident or other medical etiology; or
   5. High probability of accident or other medical etiology.