Dr Sophie Halstead | Dr Chloe Norman | Dr Gayle Hann

Documentation of child protection issues often makes us feel uneasy. We worry about what to document, the level of detail required, what we can and can’t say and even where to document!

Recognising that non-accidental injury is a possible diagnosis is a great start. From there you need to be thinking about how urgent the situation is… then there is consent, the history taking and discussion and also a thorough examination.

This article has some top tips about child protection medical examinations and a quick guide of why, how and what to document to try and ease the fear.

The GMC’s Good Medical Practice emphasises the importance of good record keeping. Their section on ‘protecting children and young people’ is particularly relevant:

The Laming Report, published in 2003, following the inquiry into the death of Victoria Climbie also offers recommendations for good record keeping in child protection cases.

Which tools I can use to help me document correctly?

  1. Medical Proforma:

Although they can be lengthy, using a proforma is a good way to make sure the correct questions are asked in the child protection medical, and answers are documented clearly and legibly which will help with information sharing. It can also act as a prompt to remind you of things you might otherwise miss! If the case ends up going to court, the proforma can be submitted as the medical notes. Hospital Trusts may have their own proformas – however the Royal College of Paediatrics and Child Health have an example proforma on their website which can also be used.

Remember to use the child’s own words as much as possible, making use of quotation marks.

Don’t forget to gain consent from the child’s parent/legal guardian. Written consent is best, however, telephone consent is also acceptable if this is not possible – don’t forget to document it!

  1. Growth Chart:

It’s good practice to record any child’s weight and height whenever you examine them, regardless of child protection concerns. There are many causes of failure to thrive – however the clinician must always remember that neglect can present as child failing to thrive.

  1. Medical Photography:

Photography is a useful aid when documenting injuries (especially for those of us with sub-average artistic skills). Professional medical photography isn’t available at every hospital and if it is, normally only within working hours. Some A&Es have their own camera that you can use out of hours.

NEVER use your own personal device to take photographs!!!

Gain written consent from the child’s parent/legal guardian when taking photographs

  1. Body Mapping:

Body maps are an essential part of a child protection investigation – so it is important that your examination is well performed and accurately documented.

Dr Gayle Hann (Consultant Paediatrician, North Middlesex Hospital) and Dr Caroline Fertleman (Consultant Paediatrician, Whittington Hospital) have recently published new, more detailed body maps in different age groups to help paediatricians make better documentation. These can be found here:


Ideally a medical assessment should be performed within 24 hours of presentation.

Ask open questions about injuries. For example – ask a child ‘what happened to your arm?’ rather than ‘did mummy hit you?’ If a reason is given for a particular injury, be sure to document this. Children under 6 years old benefit from practicing telling a story, so before you ask any difficult questions, start with something like ‘tell me about your journey to see me today, how did you get here?’ You will find that you will get a more detailed account when you then ask about any pertinent events.

Whatever you fill in on the body map should be accompanied by a written statement within your report.

On the body map, draw the injury as close to what you have seen as possible (i.e. is it a bruise? Graze? Linear cut? Scar? What colour is it?). Be sure to measure the dimensions of each injury and mark this on the body map. Each injury can be further expanded on in the accompanying written statement. Number the marks so it makes it easier to describe them in your report.

On the new body maps, there are specific areas of the body that have zoomed in images. These correspond to areas which, if injured, are more suspicious for non-accidental injury i.e. the frenulum and behind the ear. It is worth going through the body maps before you start just so you don’t forget any of these areas.

We can only improve our documentation surrounding child protection if we get actively involved and do not shy away from such cases. Practice only makes perfect!

If you feel out of your depth, always ask for senior help.

Where can I get more information?

These are a couple of books that will give you a deeper understanding of issues surrounding child protection and are perfect reading for any paediatric registrar who is regularly performing child protection medical examinations.

Dr Sophie Halstead and Dr Chloe Norman, paediatric registrars, with Dr Gayle Hann, consultant paediatrician and named doctor for Child Protection, North Middlesex Hospital

While you’re here thinking about child protection, if you would like to donate towards North Middlesex Hospital’s fantastic campaign to provide backpacks full of essentials for children going into emergency foster care, please click here to visit the JustGiving page.

References and further reading:

  1. https://www.gmc-uk.org/guidance/ethical_guidance/13428.asp
  2. The Child Protection Practice Manual. Edited by Dr Gayle Hann & Dr Caroline Fertleman. 2016
  3. http://www.londonpaediatrics.co.uk/resources
  4. The Child Protection Companion. Last published December 2017. Available on RCPCH website and Paediatric Care Online.

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