Trauma-informed examination and forensic documentation OSCE — the threat response and the court-admissible record

Station objectives

1. Recognise the freeze response during examination and respond in a trauma-informed way rather than proceeding. [1]
2. Run or support a single trained forensic interview and state the clinician's constrained role within it. [3]
3. Produce documentation that separates observed fact from clinical opinion and is contemporaneous, verbatim and complete. [2]
4. Obtain explicit and separate consent for photo-documentation and maintain the chain of custody. [2]
5. Discharge the safeguarding, reporting and follow-up duties with a safety plan in place. [1] [4]

Candidate brief

You are the paediatric registrar in the emergency department. You have 10 minutes for Station A (a non-acute child who freezes during examination) and 12 minutes for Station B (an acute presentation testing the documentation standard and disposition). Examiners score the interpretation of the threat response, the documentation discipline, the consent and chain-of-custody handling, and the safety of the disposition. [1] [2]

Station A — The freeze response during a non-acute examination

Setup: A six-year-old girl is referred after a tentative disclosure two months ago. She is quiet and avoids eye contact. Midway through the focused examination she goes completely still, silent, and apparently compliant. [1]

Expected actions:

• Recognise this as a freeze response — a threat response driven by amygdala activation and prefrontal suppression — not cooperation. [1]
• Pause the examination; slow down; name what you see gently ("you've gone very quiet — we can stop if you need to"). [1]
• Give a genuine exit and restore the child's sense of agency before continuing or deferring. [1]
• State that misreading the freeze as "fine" and proceeding re-traumatises the child. [1]
• Confirm that the history was taken once by a trained forensic interviewer and that you did not re-interview. [3]

Common errors the examiner will trap: forcing the examination through the freeze; treating the child as "difficult" or "unreliable"; re-interviewing the child about the detail of the abuse; promising secrecy; and concluding "no abuse because no findings". [1] [4]

Station B — The documentation standard and disposition

Setup: A four-year-old boy presents after an acute inflicted injury. He is stable. You must produce the record, handle photo-documentation, and arrange disposition. [2]

Expected actions:

• Confirm resuscitation, analgesia and bleeding control came first; the child is separated from the suspected perpetrator. [1]
• State and apply the documentation principles: contemporaneous, objective, verbatim history, opinion separated from fact, complete (negatives recorded), signed and dated with photo references. [2]
• Demonstrate separating fact from opinion: "a 2 cm bruise on the left pinna, photographed with a scale" (fact), then "in my opinion this distribution is not consistent with the offered fall mechanism" (opinion). [2]
• Obtain explicit and separately documented consent for photo-documentation; include a scale and colour reference; label and store securely. [2]
• Maintain the chain of custody for any forensic samples — every transfer signed, no sample unattended. [2]
• Close with the mandatory report, a safety plan so the child is not returned to an unsafe setting, the medico-legal report within the local deadline, and a two-week and two-to-three-month follow-up. [1] [4]

Common errors the examiner will trap: writing notes from memory hours later; blending opinion into fact; paraphrasing the disclosure; skipping the separate consent for photos; leaving a chain-of-custody gap; and discharging the child without a safety plan or follow-up. [2]

Marking domains

• Threat response — the freeze is recognised and the encounter adjusted, not forced. [1]
• Documentation discipline — contemporaneous, objective, verbatim, opinion separated, complete; fact and opinion demonstrated separately. [2]
• Consent and chain of custody — separate consent for photo-documentation; unbroken, signed chain for samples. [2]
• Safeguarding and follow-up — mandatory report, safety plan, medico-legal report within deadline, therapy referral, and the two-week and two-to-three-month reviews. [1] [4]