Child abuse: a model for the use of structured clinical forms

To assess the effectiveness of structured forms in the collection and documentation of information essential to the evaluation of abused children.

Retrospective chart review.

Five hundred sixty-seven children were evaluated for physical or sexual abuse during a 24-month period.

Specific items crucial to the evaluation of abuse were selected for both physical and sexual abuse. By using these items as markers, we compared the data obtained and documented during abuse evaluations after the introduction of the forms with those obtained before their introduction. The information that occurred more frequently when using the structured forms included: a history of the assault from both the child and an adult (and in cases of physical abuse, a developmental history); specific sexual acts; mechanism of injury; a detailed description of the genital examination; drawings of findings (both sexual and physical); documentation of laboratory studies, photographs, and radiographic studies; and reporting to Child Protective Services.

Structured forms significantly increased the information collected and documented in medical records during evaluations of abused children. These forms were found to be more effective than the previously used unstructured, institutional form.