Electronic health record documentation of social determinants of health and social needs of children admitted to the hospital with concern for maltreatment

Abstract

Background

Hospitalized children with concern for maltreatment require a thorough assessment of their environmental risks or social determinants of health (SDoH), information that is critical for discharge planning. However, there is often inconsistent provider SDoH documentation and location within the electronic health records (EHR).

Objective

To describe the frequency and types of child maltreatment, associations with SDoH/social needs and abuse type, and location and provider patterns of documentation in the hospital EHR.

Participants/Setting

Children 0–5 years of age who were admitted to a tertiary pediatric medical center with concern for maltreatment from 2016 to 2020.

Methods

Descriptive, correlational study design. Frequency and type of child abuse, SDoH assessment and location, and discharge needs were collected from the EHR.

Results

251 children were hospitalized with concern for abuse (neglect 94 [37.4 %], physical abuse 80 [31.8 %], combined abuse types 71 [28.3 %], and other types 6 [2.5 %]). There was inconsistent collection of data on SDoH, in terms of which professionals did the collecting and where in the EHR it was documented. Common SDoH/social needs included CPS involvement (49 %), food (37.8 %), financial insecurity (35.1 %), substance exposure (25 %), and transportation needs (24 %). Associations varied between SDoH/social needs and abuse types. While cases involving neglect were commonly discharged to their known home (72.3 %) and combined types into foster placement (60.5 %), physical abuse discharges were more equally distributed between known home (47.5 %) or foster placement (41 %).

Conclusion

Given the lack of standard protocols for EHR documentation, critical information could be missed and/or miscommunicated. Interdisciplinary access in a consistent location in the EHR could provide improved surveillance and optimize discharge service planning.