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Documentation of Child Maltreatment in Electronic Health Records

Canan Karatekin1, Brandon Almy1, Susan Marshall Mason1

  • 11 University of Minnesota, Minneapolis, MN, USA.

Clinical Pediatrics
|November 24, 2017
PubMed

Insights

Child maltreatment codes in electronic health records are rarely used, affecting early intervention and public health data. This study highlights underdocumentation despite its importance for surveillance and research.

Area of Science:

  • Public Health
  • Pediatrics
  • Health Informatics

Background:

  • International Classification of Diseases (ICD) codes are crucial for child maltreatment surveillance and research.
  • The actual utilization of these codes in clinical practice remains largely unquantified.

Purpose of the Study:

  • To determine the prevalence of maltreatment-related ICD code usage in a large pediatric health system.
  • To analyze demographic characteristics of youth assigned these codes.
  • To compare findings with existing literature on child maltreatment reporting.

Main Methods:

  • Extracted data from electronic health records for individuals aged 0-21 years over a 4-year period.
  • Focused on 15 specific maltreatment-related International Classification of Diseases, Ninth Revision, codes.
  • Calculated the percentage of youth with assigned maltreatment codes within a large medical system.

Main Results:

  • Only 0.02% of approximately 2.5 million youth encountered had a maltreatment-related ICD code.
  • This low prevalence aligns with findings from previous studies.
  • Documented rates are significantly lower than those from self-report, informant-report, or Child Protective Services referrals.

Conclusions:

  • Underdocumentation of child maltreatment in electronic health records is a significant issue.
  • This lack of documentation can impede early intervention efforts.
  • It also compromises healthcare coordination, resource allocation, and the accuracy of public health surveillance data.

Keywords:
International Classification of Diseasesadverse childhood experiencesneglectphysical abusepsychological maltreatmentsexual abuse

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