When treating children, in addition to details of examination, diagnosis and treatment provided, it is good practice to record:
- who accompanied the child and, if not the parent, their relationship to the child
- observations of behaviour, not only physical signs
- a summary of any discussions with the child and parent.
These recommendations apply at any time, even when there are no concerns about the child. When there are child protection concerns, the following additional points are particularly pertinent:
- record observations and reasons given for seemingly trivial injuries which may, over a period of time, show a repeating pattern of injury
- make diagrams in addition to written descriptions (drawings, either freehand or on a mouth, face or body map proforma (download face map proforma) or clinical photographs with consent) clearly labelled with the child’s name and date
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- record observations in a way that will be understandable to colleagues so that, even if no single team member gets to know the child well, a written record builds up over time. This overcomes the problem that abusers sometimes avoid detection by taking a child to different practitioners on different occasions so that no-one picks up on ‘the big picture’
- clearly state the difference between the facts and your opinion
- keep administrative notes such as attendance, non-attendance and cancelled appointments in addition to the clinical notes
- keep a list of questions to ask yourself when assessing a child, in paper based (print question prompts) or electronic format (view example below).
The clinical records should be:
- accessible only to health professionals who 'need to know'
- readily accessible to health professionals who need to know, so should be stored in one place with the clinical records
- stored securely: paper-based records should be stored in locked filing cabinets in rooms accessible only to staff, and never left unattended when in use; electronic records should be password protected.
Further guidance on clinical record keeping is available from other sources.36
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