Child Abuse Reporting and Documentation

CLINICAL GUIDELINES

All physicians, nurses, and other healthcare workers are considered mandatory reporters of suspected abuse or neglect. Mandated reporters must notify the appropriate Child Protective Services agency, a law enforcement agency, or a state’s toll-free child abuse reporting hotline when they have reason to suspect that a child is being abused or maltreated in the course of their professional duties. All states have mandatory reporting laws based on public law.
The purpose of the reporting statute is to identify abused, and neglected children as soon as possible to protect them from further harm. By failure to report, mandated reporters may be guilty of a Class A misdemeanor and may be civilly liable for damage caused by such failure.
All infants and children should be screened for possible abuse, and neglect. Types of abuse that must be reported include physical abuse, physical neglect, sexual abuse, sibling abuse, and emotional neglect. Another form of abuse that must be screened for is Munchausen syndrome by proxy (Chart 30-1).
Child abuse reports remain confidential, and disclosure of this information is limited to official organizations designated to investigate child abuse. Privacy standards as outlined in the Health Insurance Portability Accountability Act of 1996 (HIPAA) must be followed to ensure confidentiality.
Mandated reporters are provided immunity from civil and criminal liability as a result of making a report of known or suspected child abuse, or neglect as long as the report was made in good faith and without malicious intent.
No colleague, supervisor, administrator, or healthcare prescriber may impede or inhibit such reporting duties, and no person making such report shall be subject to any sanction for making such a report.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

If abuse or neglect is suspected because of the child’s report or a caregiver’s report or because the history given does not correspond to the clinical presentation, a complete history and physical assessment of the child should be completed.
Obtain statements separately from the family members/guardians and the child. Interview with openended questions and with language developmentally appropriate for child.
If a language barrier makes it difficult to obtain history, make sure the interpreter is not a family member, especially if abuse is suspected.
Have available age-appropriate toys or games to distract the child during the examination.
Any person suspected of being involved in the abuse should not be present during the physical examination. Older children may prefer to be examined without the presence of their caregiver. The child’s right to privacy needs to be respected. However, during any examination of the genitalia, a second healthcare provider should be in the room.
Allow the child to remain fully clothed during history taking.
Maintain privacy for the child.
Explain to the child and family what to expect during the physical examination.
Explain to child how any specimens may need to be obtained (e.g., if needed, show child swabs for cultures).
Show equipment and let child handle, as appropriate, to familiarize himself or herself with it.

Determine reliability of historian providing information about the child. It is very important in abuse cases to get an accurate history.

CHART 30-1 Types of Child Abuse

Category	Description
Physical abuse	An injury intentionally inflicted on a child by a caregiver, paramour of a parent, or anyone residing in the child’s home
Sexual abuse	The use of a child for sexual gratification or financial gain, by an adult or older child, whether by physical force, coercion, or persuasion; includes activities such as exhibitionism, pornography, genital fondling, attempted or actual anal, vaginal, or oral intercourse
Neglect	Acts or omissions by the perpetrator that fail to meet the child’s needs for basic living, including food, hygiene, medical care, clothing, and a safe environment
Emotional or psychological abuse	Pattern of damaging interactions between parents and child (belittling, shaming, threatening or committing violence against the child or child’s loved ones or objects, making the child feel unsafe, encouraging developmentally inappropriate behaviors, unreasonably limiting activities or social interactions, rejecting the child) that result in impaired growth, negative self-image, or disturbed child behavior
Munchausen syndrome by proxy	Also known as pediatric condition falsification, is a form of medical abuse in which the child is subjected to an “illness” induced or fabricated by a parent or caregiver. The affected parent or caregiver seeks medical care for the child’s fictitious illness and provides a fictitious history to support the illness. The fabricated or induced illness often results in the child being subjected to numerous unnecessary, invasive laboratory studies; hospitalizations; or surgeries

KidKare If a colposcope is used, explain to the child that it magnifies her “private area” like the otoscope magnifies “things inside your ear.” Let her look through the colposcope and show how it magnifies a character in a book or whatever else is readily available.

PROCEDURE
Conducting the Health History Interview and Physical Examination

Steps	Rationale/Points of Emphasis
1 Obtain health history. See Table 30-1 for topics to be covered and key aspects to determine during the interview. Record information exactly as given by informant.	Make sure history is factual; record observations, not conclusions; and record direct quotes. Use quotation marks to denote exact words said by the informant.
2 Give child gown to put on and sheet to cover himself or herself.	Provides for privacy and modesty during examination.
3 Position for examination.	Helpful to have picture available to show the child various positions that he or she may need to be photographed in—knee-chest, frog-leg, and supine, and stirrups if needed. KidKare If the child is uncooperative, offer him or her the choice to sit on the family member’s lap for examination.
4 Perform hand hygiene. Don gloves.	Reduces transmission of microorganisms. Gloves should be worn for genital examination and specimen collection.
5 Complete physical examination. See Table 30-2 for summary of aspects that need to be evaluated and significance of the findings. Children who have been sexually abused must be evaluated for STIs. Conversely, if an STI is found in a prepubescent child or a sexually inactive adolescent, one must strongly consider sexual abuse.	A thorough physical examination will assist in indicating the physical signs of trauma.
6 Document visible injuries with photography and/or videotaping. Individual facility policy regarding consent for these needs to be researched.	Photographs of the injuries assist in documenting extent of injuries. Photos may be used as evidence in court case against the abuser. KidKare Continuity of care should be provided by consistent nursing personnel staying with the child throughout the physical examination and any procedures.
7 Assist child to redress and place child back in bed or other place or position of comfort. Ensure child has favorite blanket or toy if desired.	Ensures child’s privacy, modesty, and comfort are maintained.
8 Remove gloves and perform hand hygiene. Dispose of equipment and waste in appropriate receptacle.	Reduces transmission of microorganisms. Standard precautions.
9 Assist in notifying all appropriate healthcare and legal authorities of suspected abuse.	Actions required by public laws.