Trauma-informed examination and forensic documentation — formative SAQs

SAQ 1 — The non-acute assessment and the trauma-informed encounter (10 marks)

A six-year-old girl is referred to your outpatient clinic after a tentative disclosure to her teacher two months ago that her mother's partner "hurts her". She is quiet, avoids eye contact, and clings to her maternal grandmother, who is supportive. The school has already spoken to her three times. [1]

Questions

1. Outline how you would conduct this assessment, including the environment, who takes the history, and the order of the examination. (4 marks) [1] [3]
2. During the examination the child becomes mute and still. Describe the correct interpretation and your immediate response. (3 marks) [1]
3. State your documentation and disposition obligations after the assessment, including the meaning of a normal examination. (3 marks) [2] [4]

Model answer

Conduct of the assessment (4). Treat this as a non-acute, elective assessment: there is no forensic window, no kit, and no urgency. Provide a quiet, private, child-friendly room with a competent examiner and a chaperone, and minimise waiting. The history is taken once, by a trained forensic interviewer using a structured protocol such as the NICHD protocol; because the child has already been interviewed three times, the clinician listens and documents rather than re-questioning, since repeated and suggestive questioning contaminates the account and distresses her. State the limits of confidentiality, including mandatory reporting, before any history is taken. Conduct a general examination for growth, skin, and signs of other maltreatment, then a focused examination only if indicated and only at the child's pace. [1] [3]

Interpreting and responding to the freeze (3). The child has gone still, silent and apparently compliant — this is a freeze response, a threat response driven by amygdala activation and prefrontal suppression, not cooperation. Misreading it as "fine" and proceeding re-traumatises her. The correct response is to slow down, name what you see gently ("you've gone very quiet — we can stop if you need to"), give a genuine exit, and restore her sense of agency before continuing or deferring. [1]

Documentation and disposition (3). Write the record contemporaneously: the verbatim history in her own words, observed findings on body diagrams, and clinical opinion clearly separated from fact. A normal examination does not exclude abuse — most confirmed cases have normal or non-specific findings — so the disclosure and context carry the diagnosis and the report follows from that. Make a mandatory child-protection report on reasonable belief, agree a safety plan so she does not return to the alleged perpetrator, refer for trauma-focused therapy, and arrange a two-week and a two-to-three-month review that repeats serology where indicated and confirms the safety plan is working. [2] [4]

SAQ 2 — Forensic documentation and the court-admissible record (10 marks)

You examine a four-year-old boy brought to the emergency department after an acute inflicted injury. He is stable. The child-protection team and police are involved. A junior doctor asks you what makes the documentation "forensic" rather than just clinical. [4]

Questions

1. List the documentation principles that make a record contemporaneous and court-admissible, distinguishing them from a routine clinical note. (5 marks) [3] [4]
2. Describe how you would handle photo-documentation and the chain of custody for any forensic samples. (3 marks) [4]
3. Explain how observed fact and clinical opinion must be separated, and why, using a worked example. (2 marks) [3]

Model answer

Court-admissible documentation principles (5). The record is contemporaneous — written during or immediately after the encounter, never reconstructed from memory hours later. It is objective, describing what is observed rather than what is inferred. The history is recorded verbatim in the child's own words, not paraphrased. Clinical opinion is clearly separated and labelled, never blended into the factual description. The record is complete — negatives as well as positives — and is signed, dated, legible, with photo references. Together these are what let the record survive cross-examination where a memory-based, opinion-laced note would collapse. [3] [4]

Photo-documentation and chain of custody (3). For photo-documentation, obtain explicit and separately documented consent for the images and their storage; include a scale and a colour reference; label each image with the child's identifier and the date and time; and store them securely with restricted access for peer review and court. For the chain of custody, maintain an unbroken, documented record of who held each forensic sample from collection to laboratory — every transfer signed, no sample left unattended, no unlabelled swab. A single gap is enough for the evidence to be excluded before it reaches court. [4]

Separating fact from opinion (2). Observe and describe: "a 2 cm bruise on the left pinna, outlined on the body diagram, photographed with a scale." Then label the inference separately as clinical opinion: "in my opinion this distribution is not consistent with the offered fall mechanism." The separation matters because the court weighs the gap between the offered history and the finding; blending them makes the record unpersuasive and undermines the clinician's credibility for the cases that matter. [3]