Child Sexual Abuse Documentation in Primary Care Settings

Area of Science:

• Pediatrics
• Child Abuse and Neglect
• Primary Care Medicine

Background:

• Primary care providers (PCPs) are crucial for continuous care in children with a history of sexual abuse (SA).
• Effective management requires accurate documentation and communication of SA history within primary care settings.
• Gaps in documentation can impede appropriate mental health interventions.

Purpose of the Study:

• To assess the extent of sexual abuse (SA) history documentation by primary care providers (PCPs).
• To identify factors associated with SA history documentation in pediatric primary care.
• To evaluate the impact of PCP documentation on mental health management and referrals for children with a history of SA.

Main Methods:

• Retrospective chart review of children aged 3–17 with a history of sexual abuse (SA).
• Analysis of primary care medical records for two years post-subspecialty SA evaluation.
• Descriptive statistics and logistic regression to determine factors associated with SA documentation and mental health care.

Main Results:

• Only 43% of children had their SA history documented by their PCP.
• Documentation was more common when care was provided by resident physicians (P < .01).
• PCPs documented greater mental health management (52% vs. 23%, P < .001) and referrals for children with documented SA history.

Conclusions:

• Childhood sexual abuse (SA) history is significantly underdocumented in primary care settings.
• Improved communication and documentation mechanisms are needed to enhance PCP awareness of SA history.
• Enhanced PCP documentation of SA is linked to improved mental health care and referrals for affected children.