Safe and Effective Documentation

Documentation of information related to child trafficking in a safe and effective manner is important in providing ongoing clinical care. Knowledge of risk-factors for victimization may prompt you to screen for exploitation, risk for trafficking and other social determinants of health.

In 2018, the United States (U.S.) Centers for Disease Control and Prevention added diagnostic codes for forced labor and sexual exploitation to the revised International Classification of Diseases version 10-U.S. (ICD-10-US). The use of ICD codes for human trafficking will facilitate research to assess the immediate and long-term health impacts of forced labor and commercial sexual exploitation, identify important risk and resilience factors, evaluate the effectiveness of treatment and determine the cost of management.

As you document sensitive information, take care to preserve your patient's confidentiality and respect their choice about including sensitive information in the health record when possible. Patients may have many concerns about documentation, including:

• Fear of staff bias and discrimination related to sexual exploitation, debt bondage, undocumented immigration status, substance use, etc.
• Potential breaches in confidentiality (e.g., courts, caregivers, health administrators who access information).
• Harm at the hands of their trafficker should the latter gain access to patient records.
• Repercussions from authorities (e.g., arrest or deportation) if their exploitation status is revealed in health records.

Incorporate rights-based, trauma-informed strategies for documentation, considering the concerns and desires of patients and caregivers, as well as legal requirements, public health concerns and the needs of staff and external parties who may access records (e.g., insurance companies, courts).

When documenting your medical visit, consider the following:

• Which information is essential vs optional to include in medical records
• Who may have access to the records and under what circumstances
• Issues of mandatory reporting and legal subpoenas
• The right of the adolescent to limit parental access to reproductive health information
• Ways to limit staff and parental access to certain information in the record
  • removing ‘problem list’ and ICD codes from After Visit Summaries
  • using ‘confidential’ sections of the medical record

As appropriate, discuss these issues with the patient and their caregivers, keeping in mind patient developmental abilities and the clinical context. Documenting ICD codes and other sensitive information in electronic health records: Guidelines for healthcare professionals who encounter patients with a history of human trafficking or other forms of violence provides detailed guidance on this process. You may want to work with your legal, IT, insurance companies and other relevant stakeholders to develop optimal ways to protect health records yet allow access to necessary information by certain parties.

Additional Information

• What is Rights Based Care?
• The need for ICD Codes
• How to properly document in EMR systems