Examples of Elements Specific to Physical Abuse

Based on our results, we think that this model of a specifically designed, structured form might also be applicable in other clinical situations in which the complete and accurate recording of medical information is often critical. Acute injuries not caused by abuse, asthma, and other conditions might well be amenable to this approach to evaluation, diagnosis, and treatment. In our study, we have shown that by listing all the information required for the evaluation of abused and neglected children, pediatric residents provided more complete medical records in these evaluations. Structured forms, therefore, may be designed to accommodate multiple clinical situations and to increase the quality and quantity of information collected and recorded in various settings.