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C l i n i c a l  G u i d e l i n e s

 
Documenting Intimate Partner Violence in Medical Records
 


Checklist

In order to provide documentation that is admissible and effective in court, medical records need to include: 

  • Full identity of patient (DOB, SSN, full name)
  • Date and time of treatment
  • Full name of attending physician
  • Nature and location of all injuries
  • Victim/patient’s statements regarding who caused the injuries, how the injuries were caused and preceding history of violence
  • Full name of perpetrator and relationship with victim
  • Diagnosis and treatment
  • Photographs of all injuries – See: Consent to Photograph Form
  • Injury location chart (body map) – See: Assessment Tool
  • Documentation concerning all physical evidence recovered by health care professionals and the disposition of the evidence


AVOID pejorative language (“patient alleges …”, “Patient refuses to …”)

 
Sample Medical Documentation: OB/GYN Practice Setting[1]

What was written

What should have been written

Ob/gyn:

Hx: G2P2, 16 weeks by dates, kicked in abdomen

Dx: IUP, blunt trauma to abdomen

Rx: Prenatal vitamins, f/u clinic appt.

Med:

Hx: listing of vague medical complaints incl chest pain, problem with husband

Dx: Atypical chest pain

Rx: Clinic appt., analgesia

Psych:

Hx: Mention of abuse, sx of anxiety

Dx Adjustment disorder with anxious mood

Rx: Referral to MHC, Librium

24y/o g2p2 16 weeks gestation. Stated husband John Doe kicked her in the abdomen 2 hours ago. Pt tearful. Said “He tried to kick me several times”. Pt. has not felt fetal movement since. No vaginal bleeding, loss of fluids, cramping.

Pt states “ He used to slap me around before I got pregnant”. Since pregnant, frequency about every 2-3 weeks, usually slapping or punching. Pt reports no weapons used, no threats of homicide/suicide, and that husband has not abused two children in home. Pt reports she has not been allowed to seek prenatal care before this visit.

Pt. also complaining of anterior chest pain since being kicked today: increased with deep breathing, no radiation, no palpitations (…)

“Plan: 1) observe for 4 hrs for contractions, fetal monitoring; 2) discuss options of shelter, offer patient safety plan; 3) social service consult stat; 4) discuss importance of prenatal care with pt and husband; 5) pt consent to photograph form, picture of abdomen taken, 6)F/u clinic appt


For more information on Photo Documentation and Forensic Evidence Collection:

Family Violence Prevention Fund, National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings (Appendix K) http://endabuse.org/programs/healthcare/files/Consensus.pdf go to page 59/Appendix F

 

For more general information on this topic:

“Documenting Domestic Violence: How Health Care Providers Can Help Victims”, by Nancy E. Isaac and V. Pualani Enos, National Institute of Justice, Research in Brief, Sept 2001. http://www.ncjrs.org/pdffiles1/nij/188564.pdf

Sherri L. Schornstein, Domestic Violence and Health Care: What Every Professional Needs to Know, Thousand Oaks, CA, London and New Delhi: Sage, 1997 (details about legal and court issues)

[1] adapted from Improving the Health Care Response to Domestic Violence: A Response Manual for Health Care Providers,” produced by Family Violence Prevention Fund, San Francisco, CA 1998


 

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