Let the Record Speak: Medicolegal Documentation in Cases of Child Maltreatment

Improving Quality of Care in Hospitals for Victims of Elder Mistreatment: Development of the Vulnerable Elder Protection Team

“…The VEPT medical provider comprehensively documents all findings, which may be critical for future legal processes but is often incomplete and inadequate in current practice, even for child abuse. 50,51 Additionally, the VEPT medical provider photographs injuries and conducts a sexual assault forensic exam when appropriate. All VEPT providers have received appropriate needed training to perform sexual assault forensic exams.…”

Medical neglect and pediatric obesity: Insights from tertiary care obesity treatment programs

“…Even in cases of physical abuse, if medical documentation is inadequate, it is difficult to substantiate the abuse (Jackson, Rucker, Hinds, & Wright, 2006). The importance of clear medical records, including complete history, severity of the medical condition, and inconsistencies between the progression of the medical condition and parental report of behavior change, has been discussed for some time (Solomons, 1980).…”

“…The importance of clear medical records, including complete history, severity of the medical condition, and inconsistencies between the progression of the medical condition and parental report of behavior change, has been discussed for some time (Solomons, 1980). Providers are encouraged to use direct language; use of the terms "rule out" and "alleged" may increase ambiguity in the medical record (Jackson et al, 2006). We recommend that health care providers document in the medical chart that weight stabilization is medically necessary, with the presence of imminent harm or potential for harm of continued weight gain.…”

Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults

“…The importance of clinician documentation of injury-related findings in children for child abuse investigation is well-recognized, 4,5 and research has shown that injury documentation in this population is often incomplete and inadequate. [5][6][7][8] Reasons likely include clinicians' lack of training, time limitations, and the low immediate clinical significance of some injuries and physical findings. 9 Additionally, potentially valuable ancillary strategies to enhance documentation of injuries such as photography are currently underutilized, 9,10 due to technical challenges and privacy concerns.…”