16: Records and Reports

Please note that this chapter is pending an update. For information on when this is due, please contact the PCO UK Team.

16.1.1 Following the death of Victoria Climbié from child abuse and neglect in 2000, Lord Laming conducted an inquiry and reported on his findings in 2003 583. Made a number of recommendations for health. Recommendations 65-80 in particular refer to record keeping, reports and management. These are the cornerstone for best practice for paediatricians and have been included in this chapter.
16.1.2 Paediatricians play an important role in the assessment and management of children where there are suspicions of abuse and neglect. Any record, report and/or statement made following an assessment must be full, fair and accurate
16.1.3 The use of a medical proforma (see Appendix 1) is recommended practice and prompts the practitioner to structure the consultation (including the history, examination, investigations, opinion and action plan), capture and record the detail, act as an ‘aide memoire’ and develop a report and/or police statement. Body maps facilitate drawings of visible lesions and injuries, including genital and anal findings, which should be corroborated by photo-documentation. See Chapter 17.
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