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Ethics & Law · single question

When documenting suspected abuse or assault, which of the following should NOT be included in the report?

  1. Documentation of physical evidence such as an object or pattern consistent with the injury
  2. Objective physical findings observed on examination
  3. The patient's own account of what happened, recorded in their words
  4. The dentist's personal opinion or conclusion about who caused the injuries
Show answer and explanation

Correct answer: D. The dentist's personal opinion or conclusion about who caused the injuries

  • A. Physical evidence consistent with the injury is a legitimate objective observation and should be documented factually.
  • B. Objective findings — location, size, color, and stage of injuries, ideally with photographs and a body diagram — are the core of the report.
  • C. The patient's account SHOULD be recorded, ideally verbatim and in quotation marks, since it is primary evidence.
  • D. CORRECT — this should NOT be included. The reporter documents OBJECTIVE FINDINGS and the patient's statements; assigning blame or drawing conclusions about a perpetrator is the role of investigative and legal authorities. Speculation in a clinical record undermines the report's credibility and can prejudice the investigation.

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