B4. Written Documentation

These recommendations are for pediatric examiners on written documentation of medical forensic care.

Ensure completion of all documentation. Examiners are responsible for documenting the medical forensic details of the examination in the prepubescent child’s medical record. All aspects of care should be documented: consent, the medical history, the examination (including written descriptions, diagram/body map rendering, and interpretation of findings), consultant reports (if done), forensic samples collected (if done), testing done and/or treatment rendered and results as available, descriptions of photographic images taken, a discharge plan, and follow-up care scheduled and referrals given.[1] Examiners also need to document this data on jurisdictional exam report forms. If examiners are called to testify in a legal proceeding, they may use this report to recall their encounter with the child (Day & Pierce-Weeks, 2013).

Document physical trauma using standard terminology and descriptive language. At a minimum, descriptions should include the type of injury (see below), but not speculate on its cause. However, if the child details the origin of an injury, it is appropriate to document her/his words in quotations. In addition to written descriptions, physical findings should be noted on body diagrams/maps and photo-documented. (See B6. Photo-Documentation) Also, samples collected from injuries should be noted.

Accurately reflect in the written record the child’s demeanor, statements made by the child during the course of care, and the caregiver’s statements regarding the history of events. All such statements, and the examiner questions, must be recorded verbatim. Such documentation can be admitted as evidence at trial in most states. (Also see B5. Medical History)

Ensure that examiners are instructed and supervised on proper written documentation. The medical record must be an accurate and thorough reflection of the examination and stand on its own (Kaplan et al., 2011). Pediatric examiners should be educated on: the importance of proper medical forensic documentation in child sexual abuse cases; the need to be objective in their documentation; the need to be consistent in documentation across these types of cases; how to access and use their jurisdictional medical forensic documentation forms; and how to document care provided in the child’s medical record. Note the following documentation “dos and don’ts:”[4]

Encourage examiners within an exam facility, jurisdiction, or region to devise an appropriate record review process tailored to their needs. In addition to having a system for peer review as discussed in A4a. Pediatric Examiners, consider having a clinical director or supervisor at the exam site systematically review documentation related to the examination. In some jurisdictions, review of non-physician examiner’s documentation by a medical director or supervisor is required. These reviews can serve to increase overall examiner effectiveness by ensuring that reports are completed according to policy, assessing staff training needs, considering acceptable procedures for amendments to the record, troubleshooting for potential problems, and identifying trends.

Establish policies for record storage, release, and retention. (Also see B6. Photo-Documentation) Pediatric examiners, as well as those involved in health care facility records management, should understand the record storage, release, and retention issues in these cases and if/how they differ for various populations of victims of sexual violence (e.g., prepubescent children, adolescents, and adults) and other patients receiving medical forensic care in which there is digital image documentation.   

The privacy of the child’s medical records stored at health care facilities should be protected, in accordance with applicable laws. Health care facilities should have clear policies that address secure storage and retention of paper and electronic records and that limit access to the child’s records, as well as procedures for releasing written records only to those who are legally allowed access. Mechanisms to restrict access to a child’s medical records are important in all scenarios, but particularly in small and/or close-knit communities where health care facility employees may be acquaintances, friends, and family members of patients and/or suspects. (See A5b. Confidentiality and Release of Information and A5e. Evidence Integrity)

Facility retention policies for medical records must take into account the need for access to these records in criminal and civil proceedings.[7] There is no single standardized retention schedule that health care facilities and providers must follow for medical forensic exam records. Instead, they typically review and consider a variety of retention requirements (e.g., federal, state, and accrediting bodies) and other recommendations (e.g., from the AHIMA) when creating such a policy. Time frames for retention requirements can be relatively short (e.g., five to 10 years after the most recent patient encounter). These limited time frames can be problematic in terms of the needs of the justice system, including in cases of delayed reporting, delayed processing of evidentiary kits, CODIS hits,[8] cold case investigations,[9] conditions that extend the statute of limitations, and the appeals process. With this in mind, policies for medical forensic record retention should be based on justice standards, rather than traditional medical record keeping, storage, retention, and destruction policies. [10]

Medical records in these cases should not be destroyed.