You suspect that a 6-year-old female patient with multiple bruises and a broken wrist was abused. The stepmother states the patient fell down the stairs. The patient is crying and sheepishly nods in agreement with the stepmother's statements. How should you document this situation in the patient report?
A) Document any pertinent information that was said by the stepmother and child exactly in quotations.
B) Document what was said as well as your opinion that the child was too afraid to tell the truth.
C) Document only the actual exam findings. Do not document anything that was said.
D) Document who you suspect caused the injuries in the narrative so law enforcement has a record of the incident.
A
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