• A chart audit was undertaken to ascertain the content and quality of documented information present in medical records of patients with traumatic injuries seen in a tertiary care hospital. Of the records of children younger than 6 years of age with a diagnosis of fracture, burn, contusion, or intracranial injury seen in the inpatient or outpatient services during a one-year period, 60% contained inadequate data on which to determine retrospectively if the medical diagnosis of child abuse was ever considered. The medicolegal implications of this are discussed.
(Am J Dis Child 134:503-505, 1980)
Solomons G. Trauma and Child Abuse: The Importance of the Medical Record. Am J Dis Child. 1980;134(5):503–505. doi:10.1001/archpedi.1980.02130170053018
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