The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. Which is the best way for the nurse to document the findings in the patient's chart?

A) Rely on photographs of the injuries.
B) Document what the child's caregiver tells the nurse.
C) Record what the nurse observes during the conversation.
D) Use the words the child has said to describe how the injury occurred.

Question

serina mcduffie · Accepted Answer

Final Answer : D, Explanation :  When documenting the history and physical findings of suspected child abuse and neglect, use the words the child has said to describe how his or her injury occurred. Remember, the abuser may be accompanying the child. Although photographs of injury can be invaluable, they are not the best method of documentation and should not be relied upon. Although the child's caregiver may be able to provide information, that is also not the best way to document and the nurse needs to keep in mind that the caregiver could be the abuser. While the nurse will document what he or she observes, the best way to document the history and physical findings of a child suspected of being abused is to use the words the child has said to describe how his or her injury occurred.

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