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Open Access Research article

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

Kirsten McKenzie1* and Debbie A Scott2

Author Affiliations

1 Centre for Accident Research and Road Safety Queensland, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059, Australia

2 Australian Institute of Family Studies, Latrobe St, Melbourne, Victoria 3000, Australia

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BMC Public Health 2012, 12:563  doi:10.1186/1471-2458-12-563

Published: 28 July 2012

Abstract

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 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.

Keywords:
Child maltreatment; Clinical documentation; Data linkage; Injury surveillance; Morbidity data