Slide share medical records in child abuse cases
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Effective utilization of medical records in the evaluation of a case of sexual abuse, physical abuse, neglect (failure to thrive) or fatalities by a child abuse pediatrics expert can assist criminal (prosecution/defense) and civil (plaintiff/defense). Easy to understand breakdown of relevant records to request, used by child abuse pediatrician to educate protective service workers and referring attorneys for case reviews.
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Slide share medical records in child abuse cases
- 1. Child Abuse Cases Understanding Medical Records and Role of Child Abuse Expert Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 2. Sexual Abuse Case Records • Primary Care – Any prior disclosures, behaviors, signs or symptoms of potenial sexual abuse • Emergency Department and Inpatient Records – Request any forensic nurse (SANE) exam records – Photo or video documentation of injuries – Complete medical chart including laboratories • Child Abuse Pediatrics Specialist – May be part of Child Advocacy Center record – Photo or video documentation of injuries – Medical History (statements from child) – Complete medical chart including laboratories • Consider Maternal Records – If child presents with a sexually transmitted disease Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 3. Physical Abuse Case Records • Primary Care – Any prior accidents, injuries, or indications of predisposing conditions (easy bruising, previous non-abuse fractures) • Emergency Department and Inpatient Records – Radiology studies – Photo or video documentation of injuries – Complete medical chart including laboratories • Child Abuse Pediatrics Specialist – May be part of Child Advocacy Center record – Medical History (statements from child) – Complete medical chart including laboratories • Possible Specialist Visits – Examples - Genetics, Endocrine, Hematology, Orthopedics Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 4. Neglect Case Records • Primary Care – Any prior indications of neglect – Previous growth parameters (for failure to thrive) • Emergency Department and Inpatient – Complete medical chart including laboratories • Child Abuse Pediatrics Specialist – May be part of Child Advocacy Center record – Complete medical chart including laboratories • Possible Specialist Visits – Examples – Genetics and Endocrine Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 5. Fatality Case Records • Primary Care Records • Emergency Department and Inpatient Records for All Visits – All orders, notes, specialist visits – Radiology and laboratory studies • Child Abuse Pediatrics Specialist – Reports, consults • Autopsy – Photos and labs Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 6. Investigative Records • Provide investigative records to the child abuse medical expert to: – Understand if mechanism is consistent with injury – Understand statements of child/family/collateral witnesses – Understand timing of injuries – Decipher medical facts as relayed by other experts – Understand perspectives/opinions of other medical providers involved in care Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 7. Medical Research in Abuse Cases • Review relevant literature related to the topic of interest • Understand strengths and limitation of articles/studies • Apply research to the case issues at hand • Prepare and understand what a medical witness may rely upon in generating an opinion Jennifer Canter MD MPH FAAP Child Abuse Pediatrician
- 8. Fundamental Role of Expert • A medical expert in a child abuse case is an educator • Opinions and testimony are identical whether provided for prosecution/defense, or plaintiff/defense • Understanding research foundation to support opinions • Effective methods to break down complex medical language for non-medical professionals Jennifer Canter MD MPH FAAP Child Abuse Pediatrician