Documentation is crucial when dealing with victims of suspected abuse


While working in the ER of a local hospital, I witnessed a case where detailed documentation by an experienced physician helped save a 5 yr old Somali girl from ongoing psychological and sexual abuse. This little girl had been brought to the ER several times over the course of 3 months. She was brought in by her mother with several physical complaints that included lack of appetite, constipation, frequent crying and painful urination. Initial physical exams and lab tests were essentially normal. During the 4th visit, the physician decided to do a more in-depth physical assessment and full evaluation of the situation which included a psycho-social assessment of the family. The results revealed ongoing sexual and psychological abuse by a family member. The physician’s reporting and her detailed documentation of the findings help remove the perpetrator of this crime from the victim’s home and later assisted in his conviction.


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