A simple approach to improve recording of concerns about childmaltreatment in primary care records: developing a quality improvement intervention

Abstract

BackgroundInformation is lacking on how concerns about child maltreatment are recorded in primary care records. AimTo determine how the recording of child maltreatment concerns can be improved. Design and settingDevelopment of a quality improvement intervention involving: clinical audit, a descriptive survey, telephone interviews, a workshop, database analyses, and consensus development in UK general practice. MethodDescriptive analyses and incidence estimates were carried out based on 11 study practices and 442 practices in The Health Improvement Network (THIN). Telephone interviews, a workshop, and a consensus development meeting were conducted with lead GPs from 11 study practices. ResultsThe rate of children with at least one maltreatment-related code was 8.4/1000 child years (11 study practices, 2009-2010), and 8.0/1000 child years (THIN, 2009(THIN, -2010. Of 25 patients with known maltreatment, six had no maltreatment-related codes recorded, but all had relevant free text, scanned documents, or codes. When stating their reasons for undercoding maltreatment concerns, GPs cited damage to the patient relationship, uncertainty about which codes to use, and having concerns about recording information on other family members in the child's records. Consensus recommendations are to record the code 'child is cause for concern' as a red flag whenever maltreatment is considered, and to use a list of codes arranged around four clinical concepts, with an option for a templated short data entry form. ConclusionGPs under-record maltreatment-related concerns in children's electronic medical records. As failure to use codes makes it impossible to search or audit these cases, an approach designed to be simple and feasible to implement in UK general practice was recommended.

Vulnerable Family Meetings: A Way of Promoting Team Working in GPs’ Everyday Responses to Child Maltreatment?

“…The 11 practices have been described elsewhere [22]. We chose four sites where the GP lead for the audit was a child protection "expert" (held a child protection post, was involved in child protection policy or in delivering child protection training) and held regular team meetings to discuss vulnerable families [21].…”

Primary care of children: the unique role of GPs

“…9 Woodman et al's paper highlights that GPs are not good at recording concerns about possible child maltreatment in children's electronic medical record, and suggests a simple and feasible approach to help improve our systems for caring for vulnerable children. 10 Two papers give a snapshot of the challenges GPs face daily in dealing with children. Ahrensburg et al report on the challenges involved in diagnosing cancer in children, with most early symptoms being general and non-specific.…”

How do we identify and support maltreated children?

“…Woodman et al describes the process of choosing preferred codes which would be least likely to be contentious. 5 GPs may fear being challenged about or asked to justify why if they record concerns and then do not contact social care, a factor which may lead to GPs not to code their concerns (even though NICE guidance states they should record 'consider' maltreatment as part of the differential diagnosis [as opposed to 'suspecting'] but for this level of concern would not necessarily notify social care).…”

“…A recent study in the BJGP, 5 shows that rates of recording child maltreatment concerns using Read Codes remain well below those expected. An evaluation of the feasibility of standardised coding in 11 practices is in progress (the codes used in the pilot study are available online at: http://www.…”