Document only what you know based on what you saw and heard. You are not responsible for “proving” the case.25
Document everything you observed, including a detailed description of the injury.
Document everything the child said, using the child’s own words.
Document everything the caregiver said, using the caregiver’s own words.
Document what you saw and heard, NOT your assumptions or conclusions about what you saw and heard. The only opinions you should include in your records are those relevant to the dental examination and treatment. For example, after fully describing a suspicious chancre, it is appropriate and necessary to include your professional conclusion as to whether the chancre is consistent with primary syphilis. You should also include recommendations for further treatment.
Document any diagnosis and treatment recommendations, including photographs and radiographs, where appropriate.