Mandated Report Documentation (Child Abuse/Neglect)

Note Type: Mandated Report Documentation (Child Abuse/Neglect)

Author/Role: [Clinician name, credentials, and role]

Date/Time: [Date and time of note entry]

Encounter Setting: [ED / inpatient / clinic / other]

Patient Name/DOB/MRN: [Patient legal name, date of birth, and medical record number]

Confidentiality Designation

[EHR sensitivity/portal status: [sensitive/restricted / standard release]] (If restricted, document rationale tied to safety risk and who made the determination. If sensitivity segmentation is not supported, state that standard release rules apply and safety risks were reviewed per policy.)

Reason for Report

[Purpose statement documenting suspected child abuse/neglect concerns and mandated reporting actions taken]

Category of Concern: [physical abuse / sexual abuse / neglect / medical neglect / psychological maltreatment / exposure to intimate partner violence / trafficking concern / other]

Imminent Safety Concern: [yes / no] (If yes, include brief specifics relevant to immediate risk.)

Patient and Guardian Context

Legal Guardian(s): [Name(s) and relationship to child] (Document as Unknown with brief reason if not available.)

Custody Status: [parent/guardian / foster care / kinship care / residential placement / unknown]

Relevant Protective Orders: [Order type and parties / none known / unknown]

Accompanying Adult(s) at Presentation: [Names and relationships / none]

Who Provided Consent for Evaluation: [Name and role or legal authority / not applicable]

Primary Language: [Language]; Interpreter Used: [yes (in-person / phone / video) / no] (Include interpreter ID if required by policy.)

Information Sources and Interview Context

Sources: [List all sources: child statement, parent/guardian statement, other caregiver, EMS, law enforcement, school/daycare, prior records]

Interview Structure: [For each history source, note who was present and whether child and caregiver were interviewed separately]

Barriers to History: [Developmental stage, fearfulness, altered mental status, language limitations, or none identified]

Disclosures: [Document using exact patient quotes in quotation marks; note if statements were spontaneous or in response to open-ended questions; if any prompts were potentially leading, document the prompt verbatim] (Follow minimal-facts approach, documenting only information necessary for medical care and immediate safety decisions.)

Concern Summary

[Presentation and concern trigger narrative using attribution language]

Approximate Date/Time of Alleged Event(s): [Date/time or timeframe]

When Concern Became Known to Staff: [Date/time]

Timeline Discrepancies: [Delay in seeking care, changing explanations, last known well, or none identified]

Alleged Mechanism or Neglect Scenario: [Description with attribution: "Caregiver reports…", "Per EMS…", "Child states…"]

Immediate Danger Assessment:

• Child feels unsafe returning home: [yes / no] — [details]
• Alleged offender access to child: [yes / no / unknown] — [details]
• Presence of threats, weapons, severe caregiver impairment, or unsafe supervision: [yes / no] — [details]

Objective Clinical Findings

(Include this section only when injuries or neglect signs are present. Omit entirely if report is based solely on history or observed interactions.)

Injuries: [For each injury: anatomic location and laterality; size in cm; shape/pattern; color; borders; tenderness]

Burns: [Configuration; estimated depth; margins; pattern characteristics] (If applicable.)

Neglect-Related Observations: [Nutritional status, hygiene, clothing appropriateness, dental status] (If applicable.)

Photodocumentation: [yes / no]; [Obtained by]; [EHR storage location]; Measurement scale used: [yes / no]; Consent/assent obtained per policy: [yes / no / not required]

Studies Obtained: [Relevant imaging, laboratories, and consultations with key findings; note pending items as Pending]

Clinical Assessment

Concerning Features Supporting Reasonable Suspicion:

• [Feature 1, e.g., injury pattern inconsistent with reported mechanism]
• [Feature 2, e.g., developmental mismatch with reported mechanism]
• [Additional features as applicable: conflicting accounts, unexplained delay in care, relevant prior history]

Alternative Explanations Considered: [Medical mimics or alternative diagnoses considered and evaluation steps taken]

Impression: [Concise statement identifying suspected type(s) of maltreatment; state that based on information available at this time, the threshold for mandated reporting is met under reasonable suspicion] (Use "suspected" and "alleged" terminology; avoid definitive attribution of intent.)

Mandated Report Action Log

(Complete every field or explicitly mark as Unknown / Not provided / Pending.)

Oral/Initial Report:

Date/time initiated: [Date/time] — Date/time completed: [Date/time]
Agency contacted: [CPS hotline / local CPS / law enforcement / tribal authority]
Method: [phone / electronic portal / in person]
Person who received report: [Name or ID / not provided]
Report/case/reference number: [Number / not provided at time of report]
Summary of information conveyed: [Brief summary]

Written Follow-up Report:

Date/time submitted: [Date/time]
Method: [fax / electronic form / portal]
Confirmation received: [yes / no] — Confirmation number: [Number / not applicable]
Copy routed internally per policy: [yes / no]

Reporter Identity: [Reporter name, credentials, role, and business contact information]
Institutional report also filed: [yes / no] (If yes, document who submitted and how submission was confirmed.)

Notifications

Caregiver Notified of Report: [yes / no] — [By whom and when] (If no, document safety-based rationale.)

Internal Notifications: [Social work, child protection team, attending physician, risk management — list parties contacted with times]

External Notifications Beyond CPS: [Law enforcement (if separate from CPS), medical examiner, military family advocacy, tribal notification — include who, when, method, or none required]

CPS/Law Enforcement Guidance Received: [Instructions provided, by whom (name/agency) and time, e.g., do not discharge, hold until investigator arrives, okay to discharge with safety plan]

Safety Planning and Disposition

Immediate Protective Actions: [Admission for safety, discharge to safer caregiver (name/relationship), security measures, supervised visitation restrictions, emergency protective custody, or none required]

Disposition: [Where the child is going, who will supervise, transportation plan]

Follow-up and Referrals: [Child advocacy center/forensic interview pathway, primary care follow-up, wound checks, mental health supports]

Safety-Focused Return Precautions: [Specific symptoms or circumstances prompting urgent reevaluation]

Family Supports Offered: [Food/housing resources, DV resources, substance treatment referrals — note accepted or declined] (If applicable.)

Attestation

"This report was made based on reasonable suspicion using information available at the time of evaluation."

[Electronic signature with credentials and date/time]