An example of a chart to organize the medical record review for medical child abuse*

Date	Provider	Complaint	Comments
2-05-07	Jones, ENT	Recurrent OM	Mom says audiogram at Kerman Hosp. shows conductive hearing loss. He snores and mouth breathes. He has had 12 ear infections. Audiogram report says it's normal. He has had 3 documented ear infections. Mother says child has eosinophilic granulama. Not true. Child is allergic to Keflex, penicillin, and erythromycin. No evidence of drug reactions in medical record. MD says based on history, child needs T & A and PE tubes inserted.
2-17-07	Marshall Hosp. Jones, ENT	Recurrent OM	Surgery. T & A, PE tubes. No fluid noted behind ear drums. No unusual tonsilar or adenoidal pathology.
2-24-07	Jones, ENT	Postop visit	Tubes in place. Doing well.
3-11-07	Marshall Hosp. ED	Tube fell out of ear	Mom was cleaning child's ear with a water pik. PE tube came out of ear. Ref. to Dr Jones.
3-15-07	Wilson, Pediatric cross cover	Ear pain and fever	Telephone call from mom. Fever and ear pain. Child allergic to penicillin and erythromycin. Rx: Ceclor.
3-17-07	Jones, ENT	Evaluate lost PE tube	Missed appointment.

* Reviewer's comments are in italics.

From: Roesler TA, Jenny C. Medical Child Abuse: Beyond Munchausen by Proxy. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 179. Copyright © 2009 American Academy of Pediatrics. Reproduced with permission.

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An example of a chart to organize the medical record review for medical child abuse*