Neobook — clinical reference

Summary of Forms & SAEKs to be Completed

Completion of Forms

Form 22 (Section 110 of Children’s Act 38 of 2005: Reporting of abuse or deliberate neglect of a child)

NB! FORM 22 MUST BE COMPLETED AND HANDED OVER TO EITHER THE SOCIAL WORKER OR THE POLICE WITHIN A MAXIMUM OF 24 HOURS.

Form 22 triggers an immediate police investigation of possible child abuse and aims to ensure prompt action to ensure the protection and safety of the child involved.
Mandatory for ALL healthcare professionals who suspect OR confirm sexual, physical or emotional abuse, and/or deliberate neglect of a child. This includes reporting children who are exploited, are substance abusers or who are affected by caregivers who are substance abusers.
The conclusion by the doctor of suspected/actual abuse must be based on reasonable grounds of one or more of the following:
The first doctor to see the child must complete the Form 22 and hand it to the Social Worker immediately, or within 24 hours. The Social Worker will facilitate reporting of the case to the relevant authority.
After hours cases must be reported to the Police (see Resources for contacting SAPS), and a COPY of the Form 22 must be handed to a Police Officer, who will take a statement from the first contact person who attended to the child. If the child’s safety is in question, and he/she is medically well, the Police may take the child to a designated Child Protection Organisation. Alternatively, if such a child requires further medical attention, he/she must be admitted and may not be discharged unless a Social Worker has assessed that it is appropriate to do so. If the child’s safety is not in question, he/she may be discharged to the caregiver.
If the Medical Report/J88/SAECK are complete, these may be handed over to the Police at the same time, but do not delay the process of handing over the Form 22.
Photocopies may be made after hours by contacting the Nursing Night Superintendent who will open the CEO’s office for access to a photocopier. Alternatively, photos of the document may be taken.
After hours collection of the Form 22/Medical Report/J88/SAECK must be recorded on a separate Register of Issuing Form 22 (these documents are available in the ward) with a signature of the Police Officer, his/her Force number and the time of collection in the patient’s hospital record. The ORIGINAL Form 22 and the signed Register document must be handed to the Social Worker on the first normal working day.
Two copies of the above forms must be made for the doctor’s own reference and for filing in Rainbow Clinic (please hand one copy to Dr Cartwright for filing).
If all attempts to contact a Police official to collect the forms after hours fail, the child must remain temporarily admitted in hospital until the Social Worker advises that the child may be discharged.

J88 or RMMCH Child Abuse Medical Report

The J88 is a legal form in the SAECKs or is brought by the SAPS/patient’s family to record the medical findings of child abuse cases (physical and sexual). At RMMCH, it is preferable to use the RMMCH Child Abuse Medical Report (available in all wards, Emergency Department and POPD). This medical report is more comprehensive than the J88, and allows for all factors pertinent to child abuse to be documented. Medical reports must be completed by the FIRST doctor to examine the child (in the wards, the admitting registrar or intern - interns should be supervised by senior doctors). All sections must be legibly completed and all pages must be signed with the doctor’s printed name, HPCSA registration number and rank below each signature. The history given must be included and the source (i.e. the child/parent/other) must be stated. Areas that are not relevant must not be left blank, but must be clearly marked as “Not relevant”. In cases where a SAECK is used, the J88 that accompanies that kit must be used as the medical report, with any extras added by using and including the RMMCH report.
In the conclusion section, the doctor’s MEDICAL conclusions must be stated clearly e.g. “Medical findings are highly suggestive of chronic genital and anal penetrative injury”. NEVER write that there is evidence of “rape” as it is a LEGAL, not a medical term. It is vitally important to be clear about the conclusion and to attempt to avoid the use of confusing terms such as “alleged sexual abuse”. NEVER state that there is “no evidence of sexual abuse” as in more than two thirds of sexual abuse cases, the findings are within normal limits – rather state “Absence of medical findings does not exclude sexual interference, as in more than two thirds of known cases, the findings are normal”.
Two copies of the report should be made: one for the examining doctor for future use in court, and one for filing in Rainbow Clinic (please hand this copy to Dr Cartwright).
During working hours, the original Medical Report (with a SAECK if used) and the original Form 22 must be handed to the Social Worker.
After hours, the original Medical report (with a SAECK if used) and a COPY of the Form 22 must be handed to the Police.
Form 22s, Medical reports and SAECKs may never be given to the patient’s family, even if the Police tell the caregivers to bring such reports back to the Police Station.

Summary of Forms & SAECKs to be Completed

Form	Requirements during working hours	Requirements after hours
Form 22	Original handed to Social Worker as early as possible on same day	Copy handed to Police Officer at the time of examination
Register of issuing Form 22	Not necessary	Yes
RMMCH Medical Report or J88	Complete as soon as possible & hand to Social Worker	Complete at the time of examination and hand to Police Officer
Sexual Assault Evidence Collection Kit (SAECK)	All acute cases (< 72 hours) - hand to Social Worker	All acute cases (< 72 hours) - hand to Police Officer

Step by Step Guide to the Management of Child Abuse; Rainbow Clinic, RMMCH; Version: July 2023; Forms & Reports