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A simple approach to improve recording of concerns about child maltreatment in primary care records: developing a
Jenny Woodman1, Janice Allister, Imran Rafi
1UCL Institute of Child Health, MRC Centre of Epidemiology for Child Health and Centre for Evidence-Based Child Health, London.
Insights
General practitioners under-record child maltreatment concerns in electronic medical records. A quality improvement intervention recommended a new coding approach to improve data capture and auditing of child abuse cases.
Area of Science:
- Child health surveillance
- Primary care informatics
- Medical record keeping
Background:
- Limited information exists on how child maltreatment concerns are documented in primary care records.
- Accurate recording is crucial for child protection and auditing.
Purpose of the Study:
- To investigate the current recording of child maltreatment concerns in UK general practice.
- To develop and recommend methods for improving the documentation of child maltreatment concerns.
Main Methods:
- A quality improvement intervention was developed, incorporating clinical audit, surveys, interviews, and a workshop.
- Data analysis included descriptive statistics and incidence estimates from 11 study practices and The Health Improvement Network (THIN).
- Consensus development with General Practitioners (GPs) informed recommendations.
Main Results:
- The incidence of recorded maltreatment concerns was low (8.0-8.4/1000 child years).
- Despite undercoding, maltreatment information was often present in free text or scanned documents.
- GPs cited patient relationship concerns, coding uncertainty, and data privacy issues for family members as reasons for under-recording.
Conclusions:
- GPs significantly under-record child maltreatment concerns in electronic medical records.
- A simplified, feasible coding approach, including a 'child is cause for concern' red flag, was recommended.
- Improved coding is essential for effective auditing and searching of child maltreatment cases.
Background:
Information is lacking on how concerns about child maltreatment are recorded in primary care records.
Aim:
To determine how the recording of child maltreatment concerns can be improved.
Design And Setting:
Development of a quality improvement intervention involving: clinical audit, a descriptive survey, telephone interviews, a workshop, database analyses, and consensus development in UK general practice.
Method:
Descriptive analyses and incidence estimates were carried out based on 11 study practices and 442 practices in The Health Improvement Network (THIN). Telephone interviews, a workshop, and a consensus development meeting were conducted with lead GPs from 11 study practices.
Results:
The rate of children with at least one maltreatment-related code was 8.4/1000 child years (11 study practices, 2009-2010), and 8.0/1000 child years (THIN, 2009-2010). Of 25 patients with known maltreatment, six had no maltreatment-related codes recorded, but all had relevant free text, scanned documents, or codes. When stating their reasons for undercoding maltreatment concerns, GPs cited damage to the patient relationship, uncertainty about which codes to use, and having concerns about recording information on other family members in the child's records. Consensus recommendations are to record the code 'child is cause for concern' as a red flag whenever maltreatment is considered, and to use a list of codes arranged around four clinical concepts, with an option for a templated short data entry form.
Conclusion:
GPs under-record maltreatment-related concerns in children's electronic medical records. As failure to use codes makes it impossible to search or audit these cases, an approach designed to be simple and feasible to implement in UK general practice was recommended.
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