From the Guidelines
Healthcare providers in California should document suspected human trafficking in the medical record using specific, objective language that describes observed physical findings, behavioral indicators, and direct patient statements, as mandated by state laws and guidelines 1. When documenting suspected human trafficking, providers should include detailed descriptions of injuries with photographs when appropriate, inconsistencies in the patient history, controlling behaviors by accompanying individuals, and any disclosure of force, fraud, or coercion.
- Providers should use the ICD-10 code T74.51 for confirmed adult labor trafficking, T74.52 for confirmed adult sex trafficking, and corresponding suspected trafficking codes (T76.51, T76.52) when trafficking is suspected but not confirmed.
- California mandates reporting of suspected human trafficking involving minors to child protective services, but adult cases require patient consent before reporting to law enforcement, as stated in the study 1. The medical record should also document resources provided to the patient, safety planning discussions, and referrals to support services.
- Thorough documentation is essential not only for continuity of care but may also serve as evidence if the patient later seeks legal remedies or services, as highlighted in the study 1. Healthcare providers should follow their institution's protocols while maintaining patient confidentiality and prioritizing trauma-informed care approaches, as recommended by the American Academy of Pediatrics 1.
From the Research
Human Trafficking Documentation in Medical Records in California
- There is no specific evidence provided that directly addresses the documentation of human trafficking in medical records in California.
- However, studies have shown that human trafficking is a significant issue in the United States, with approximately 18,000 people being trafficked into the country each year 2.
- It is estimated that up to 80% of victims are seen by a healthcare provider, but they rarely identify themselves as victims of human trafficking, making it difficult to recognize them 2.
- Some hospitals have developed their own protocols for identifying and assisting patients who are being trafficked, but there is a wide variation in what is included on these assessment protocols 2.
- The use of a validated human trafficking screening tool and the timely provision of resources can help empower healthcare providers to identify and care for potential victims of human trafficking 3.
- Trauma-informed care is an approach that can help recognize and resist re-traumatization in healthcare settings, and it may be beneficial in caring for patients who have experienced human trafficking 4, 5.
- The development of a human trafficking flowsheet for clinical forensic examiners can help guide a comprehensive examination and address specific patient needs, optimizing trauma-informed service delivery 6.