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May 1980

Trauma and Child Abuse: The Importance of the Medical Record

Author Affiliations

From the Department of Pediatrics; the Child Development Clinic; and the Region VII Child Abuse and Neglect Resource Center of the Institute of Child Behavior and Development, University of Iowa, Oakdale.

Am J Dis Child. 1980;134(5):503-505. doi:10.1001/archpedi.1980.02130170053018

• 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)

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