Training Video

Medical Evaluation & Documentation

Trauma-Informed Care

• Informed consent must be collected from the patient before initiation of any portion of the medical exam.

• Any clinical exam relating to child maltreatment, abuse, or torture may be extremely distressing and/or retraumatizing to the patient - inducing suicidal ideation, non-suicidal self-injury, severe panic, avoidance, hostility, sleeping difficulties, etc.

• If possible and appropriate, allow the patient preferred comfort items, a trusted adult or caregiver, or accommodations that support the child.

• Be mindful that the child may have strong feelings towards providers due to their gender, age, or without clear explanations; respect that this is most likely a trauma response and, where possible, allow another provider to provide the medical assessment.

Medical History

• Many children who have been tortured do not present with physical injuries; historical injuries should be documented within the medical history.

• Ask the patient to describe injuries that resulted from torture or maltreatment; document any signs or symptoms of reported injury, the intensity and duration of symptoms following injury.

• Ask the patient to describe any long-term complications, chronic symptoms or sequelae related to torture or injuries from torture; document severity, frequency and duration.

• For each reported injury, clearly document whether the child received medical care following the injury and any pertinent information around the healing process (infection, increased pain, limited mobility, scarring, etc).

Physical Exam: Basic Guidelines

• Clear, verbalized consent from the patient is needed for all aspects of the physical exam.

• Clearly inform the child of their right to stop the exam at any time, for any reason.

• Limit unnecessary exposures of the child’s body: examine one section at a time, allowing the child to cover each area before moving to the next section. Provide additional blankets, exam gowns, and sheets when able.

• Note that many patients who have been tortured will not present with current findings for physical abuse; of patients who present with physical findings, skin injuries (non-patterned bruising, scars, abrasions) are the most common findings.³–⁶

Physical Exam: Inclusion of Photographs

• Obtain high quality photographs of all reported injuries, clearly documented with patient identifying information, detailed description, location of body, size and shape of injury.⁵

• Obtain high quality photographs of the child’s full body against a standardized background; this photo will be used to review the child’s growth and development in follow up care.⁶