There are three steps in the history taking process:
Both the child/adolescent and the parent/caregiver need to trust a medical provider in order to provide complete information, agree to the physical examination, and be open to the therapeutic experience that the visit can provide. Building rapport begins as soon as you interact with them. The techniques are the same as those used during regular, routine checks and are especially important before a physical examination related to abuse. Rapport building continues with each person individually during the taking of the history from that person.
Taking a history from the non-offending parent/caregiver without the child/adolescent present
After a brief time with all the family members together, move to taking a history from the parent/caregiver. Reassure the child/adolescent that you will be talking with him/her shortly. Provide supervision for young children while they are separated from the parent/caregiver. If both parents are present, obtain a history from each separately.
Taking a history directly from the child/adolescent
Every effort should be made to take this history without other family members present. If there are siblings present, interview each separately.
Because the medical record may be used as evidence in a legal proceeding, it is important to document responses accurately. For medical records to be admissible for prosecution purposes, they must be legible and comprehensible to people other than the creator. In order to prevent confusion and misinterpretations, avoid abbreviations when documenting findings. It is extremely important to document what was said about the abuse, using the person's own words. In addition, record the emotional affect and reactions of the parent/caregiver and child/adolescent when telling about the abuse.
For a more complete explanation of good documentation, see DOCUMENTATION: Documenting the History.
For a more complete explanation of good documentation, see the Documentation chapter.