Resident Documentation of Diagnostic Impression in Sexual Abuse Evaluations

Clinical Pediatrics - Tập 36 Số 12 - Trang 691-694 - 1997
Juan M. Parra1, Rebecca L. Huston, D. Michael Foulds2
1Department of Pediatrics, University of Texas Health Science Center, San Antonio 78284-7808, USA.
2Department of Pediatrics, Division of General Pediatrics, The University of Texas Health Science Center, at San Antonio, Texas

Tóm tắt

In sexual abuse evaluations, the documentation of the examiner's diagnostic impression is essential. If the diagnostic impression is not documented, the examiner will have to rely on memory rather than the medical record when called to testify. The purpose of this study was to determine whether pediatric residents adequately document their diagnostic impression in child sexual abuse evaluations. We performed a three-year retrospective chart review from patients 0-17 years of age who were evaluated at our emergency room for suspected sexual abuse. We reviewed 1,487 charts for historical information, physical findings, and diagnostic impression. Physical findings were categorized as normal, nonspecific, suggestive, or indicative of penetration. In 77% of cases (N=256) with hymenal findings indicative of penetration and 84% of cases (N=31) with vaginal findings indicative of penetration, residents recorded no impression or a nonspecific impression. Results were similar for vulvar and rectal findings indicative of penetration. Residents fail to document an adequate interpretation of their physical examinations in sexual abuse evaluations.

Từ khóa


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Thông tin xuất bản

Clinical Pediatrics

Tập 36 Số 12

691-694

Thông tin tác giả