Question

You have been called for a​ 2-year-old female with an arm injury. The child presents with deformity and bruising to her left forearm. When​ asked, the mother states that the child fell from the​ bed, but the father states that his daughter fell down the stairs. Given the inconsistent​ stories, you are suspicious of child abuse. Which narrative would be most appropriate when documenting this​ situation?

A."Mother and father cannot agree on how their daughter got the bruise and deformity to the​ arm."
B."Patient appears to be​ abused; the police will be called and the physician in the ED will be​ notified."
C."Patient fell off of bed injuring left armdashper ​mother; patient fell down stairs injuring left armdashper ​father."
D."Patient has injuries consistent with child​ abuse; the mother and father cannot determine how the patient was​ injured."

Answer 1

Option C, which records both parents' statements about the child's injury without drawing premature conclusions of abuse, is the appropriate choice for documentation. Health professionals should report suspicions to child protection services and focus on treating the child's immediate injuries.

Step-by-step explanation:

The most appropriate narrative to document in a situation where there is suspicion of child abuse due to inconsistent stories about an arm injury is C: "Patient fell off of bed injuring left arm—per mother; patient fell down stairs injuring left arm—per father." This option is factual and non-accusatory, recording exactly what was told by each parent without premature conclusions of abuse. It is critical to maintain a professional tone in documentation and leave investigations and determinations of abuse to the appropriate authorities.

In cases of suspected child abuse, it's essential to report the concern to child protection services so that they can begin a proper investigation. While health professionals can be alert to signs and symptoms that might indicate abuse, such as fractures or bruising, their role is to record observations and ensure the child receives appropriate medical care for their immediate injuries, which can include potential fractures such as a distal humerus fracture from a fall.