This information must be recorded accurately, completely and legibly.
Record the following specfic historical aspects:
the date, time, location, referral source and the person(s) accompanying the child to the medical site;
the names, addresses and telephone numbers of all individuals involved in the evaluation, whether the interview was conducted jointly, and who was present in the room during the evaluation;
duration of time elapsed between the occurrence of suspected abuse and the child's initial disclosure;
duration of time elapsed between the initial disclosure and the current visit to the health care practitioner;
whether the child's statement describing the abuse to the interviewer was spontaneous. If not, what the interviewer asked to elicit the statement;
the emotional state and physical condition of the child at the time of the statement;
if the initial disclosure of abuse occurred at the medical site, transcribe the words used by the child to describe the event(s). Place the child's words in quotation marks.
