Trauma and child abuse. The importance of the medical record.

A chart audit was undertaken to ascertain the content and quality of documented information present in medical records of patients with traumatic injuries seen in a tertiary care hospital. Of the records of children younger than 6 years of age with a diagnosis of fracture, burn, contusion, or intracranial injury seen in the inpatient or outpatient services during a one-year period, 60% contained inadequate data on which to determine retrospectively if the medical diagnosis of child abuse was ever considered. The medicolegal implications of this are discussed.