Quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations

McKenzie, Kirsten & Scott, Debbie (2012) Quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations. BMC Public Health, 12(563), pp. 1-15.

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Background While child maltreatment is recognised as a global problem, solid epidemiological data on the prevalence of child maltreatment and risk factors associated with child maltreatment is lacking in Australia and internationally. There have been recent calls for action to improve the evidence-base capturing and describing child abuse, particularly those data captured within the health sector. This paper describes the quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations in Queensland, Australia.

Methods This study involved a retrospective medical record review, text extraction and coding methodology to assess the quantity of documentation of risk factors and the subsequent utility of data in hospital records for describing child maltreatment and data linkage to Child Protection Service (CPS).

Results There were 433 children in the maltreatment group and 462 in the unintentional injury group for whom medical records could be reviewed. Almost 93% of the any maltreatment code sample, but only 11% of the unintentional injury sample had documentation identified indicating the presence of any of 20 risk factors. In the maltreatment group the most commonly documented risk factor was history of abuse (41%). In those with an unintentional injury, the most commonly documented risk factor was alcohol abuse of the child or family (3%). More than 93% of the maltreatment sample also linked to a child protection record. Of concern are the 16% of those children who linked to child protection who did not have documented risk factors in the medical record.

Conclusion Given the importance of the medical record as a source of information about children presenting to hospital for treatment and as a potential source of evidence for legal action the lack of documentation is of concern. The details surrounding the injury admission and consideration of any maltreatment related risk factors, both identifying their presence and ruling them out are required for each and every case. This highlights the need for additional training for clinicians to understand the importance of their documentation in child injury cases.

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3 citations in Web of Science®

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ID Code: 52847
Item Type: Journal Article
Refereed: Yes
Keywords: Child maltreatment, Clinical documentation, Data linkage, Injury surveillance, Morbidity data
DOI: 10.1186/1471-2458-12-563
ISSN: 1471-2458
Subjects: Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000)
Divisions: Current > Research Centres > Centre for Accident Research & Road Safety - Qld (CARRS-Q)
Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Current > Schools > School of Psychology & Counselling
Copyright Owner: Copyright 2012 McKenzie and Scott ; licensee BioMed Central Ltd.
Copyright Statement: This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Deposited On: 31 Jul 2012 22:41
Last Modified: 11 Apr 2013 15:55

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