10 tips for documenting domestic violence

In Brief

Follow these ten tips for documenting a patient's domestic violence injuries clearly, accurately, and objectively.

Domestic violence affects women and men of all ages. In the United States, about 1.3 million women and 835,000 men are physically assaulted by an intimate partner each year.¹

The healthcare community plays an important role in screening, treating, and documenting domestic violence. A healthcare facility may be the first and only setting for disclosures of domestic violence in a safe forum. Follow these 10 guidelines for documenting signs of potential domestic violence:

1. Objectively document any injuries suggesting domestic violence. With the patient's permission, take photographs of all injuries known or suspected to have resulted from domestic violence.² If that's not possible, clearly document the location, number, type, and characteristics of injuries, using an injury location chart or body map.
2. Use quotation marks to denote the patient's own words or use phrases such aspatient statesorpatient reportsto indicate information that came directly from the patient.² When you use quotation marks, the statement must be an exact repetition of what the patient said, not paraphrased.
3. Avoid legalese. Document in a factually neutral manner, avoiding phrases or words such as alleges, which have specific legal meanings.
4. Identify the person who hurt the patient as stated by the patient, using quotation marks and recording the identifying information.² For example, "my husband," "my stepmother," or "my wife kicked me."
5. Don't write your personal conclusions about the situation, such aspatient is a battered woman.² Conclusions without sufficient accompanying factual information are generally inadmissible in court. Document the facts clearly and objectively and let others draw conclusions in the future.
6. Don't put the termdomestic violenceor abbreviations such as "DV" in the diagnosis fields of a patient's medical records. These terms don't convey factual information. It's up to the courts to determine whether domestic violence has occurred.²
7. Record your observations of the patient's general appearance or demeanor.² For example, Patient crying and seems agitated.
8. Record the time of day the patient is examined. If possible, indicate how much time has passed between the incident and the patient's arrival at your facility.²
9. Write legibly or use a computer to document the patient's medical information.
10. Following facility policy and procedure and state law, report any disclosure from your patient of child or elder abuse to local authorities. It's your legal obligation. Know your state's reporting laws, and document whom you notified of the suspected abuse.

Remember to interview patients alone because abusers often accompany their victims when seeking healthcare. Ask patients whether they're safe at home or whether they can stay somewhere else. If a referral to a social worker is needed, your documentation should reflect this, as well as any referral to a patient advocate for domestic violence.

Careful documentation that presents the facts without implying blame helps ensure that patients in abusive situations get the help they need to stay safe.