Accident or child abuse? Terminological requirements for clinical documentation of child injuries

Résumé

Since children are usually accompanied by an adult when they arrive at a healthcare facility, information about how the injury occurred also originates from the adult. To rule out the possibility of child abuse, the physician attending to child injuries should pay particular attention to whether the trauma marks on the child’s body correspond to the circumstances of the injury as described by the adult, e.g., whether the injury could have occurred spontaneously in the event of an accident, taking the child’s level of physical and mental maturity into consideration. As physical injuries to both the soft tissue and the skeleton heal more quickly in children than in adults, and the injury itself is the main evidence in any criminal proceedings, great care must be taken in documenting injuries. For this reason, forensic medicine has developed specialized literature on the requirements for documenting injuries in children. Such literature discusses in more detail the characteristics of each type of injury suffered by children. However, a challenging circumstance in clinical care is that the international diagnosis classification (ICD) currently used in Hungary does not treat child injuries separately, thus the pathologies, especially for bone fractures, cannot be coded in sufficient detail. In the present case study, we discuss the terminology used to describe child injuries in detail in comparison with the terminology used for adult injuries based on the literature. We then analyze the documentation of blunt force injuries in 45 clinical records of child injuries, with a special focus on the terms used to describe the external trauma marks and the pathology.