You suspect that a 6-year-old female patient with multiple bruises and a broken wrist was abused.The stepmother states the patient fell down the stairs.The patient is crying and sheepishly nods in agreement with the stepmother's statements.How should you document this situation in the patient report?
A) Document who you suspect caused the injuries in the narrative so law enforcement has a record of the incident.
B) Document what was said as well as your opinion that the child was too afraid to tell the truth.
C) Document only the actual exam findings. Do not document anything that was said.
D) Document any pertinent information that was said by the stepmother and child exactly in quotations.

Question

Quizplus · Accepted Answer

Documenting the exact statements made by both the stepmother and the child in quotations ensures an accurate and unbiased record of the encounter. This approach captures what was said without inserting personal opinions or suspicions, which is crucial for maintaining professionalism and objectivity in medical documentation.

You Suspect That a 6-Year-Old Female Patient with Multiple Bruises