Domestic Violence/Intimate Partner Violence: Applying Best Practice Guidelines

Documentation and Follow-up

Introduction

Defining the Problem

Statistics

Identifying Abuse

Consequences of Violence

Risk Factors for IPV/DV

Dynamics of Abuse

Select Populations and IPV/DV

Barriers to the Identification of Violence

Best Practice Guidelines

Reporting IPV/DV

Documentation & Follow-up

Safety Planning

Conclusion

Resources

References

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Test

Exit to Menu



Documentation is critical, both for the protection of the patient and of the healthcare provider. Document relevant history, including:

  • Chief complaint or history of present illness.
  • Record details of the abuse and its relationship to the presenting problem.
  • Document any concurrent medical problems that may be related to the abuse.
  • For current IPVDV victims, document a summary of past and current abuse including:
    • Social history, including relationship to abuser and abusers name if possible;
    • Patient's statement about what happened, not what lead up to the abuse (e.g." boyfriend John Smith hit me in the face" not "patient arguing over money");
    • Include the date, time, and location of incidents where possible;
    • Patients appearance and demeanor (e.g. "tearful, shirt ripped" not "distraught");
    • Any objects or weapons used in an assault (e.g. knife, iron, closed or open fist);
    • Patients accounts of any threats made or other psychological abuse;
    • Names or descriptions of any witnesses to the abuse.

Document results of physical examination:

  • Findings related to IPV/DV, neurological, gynecological, mental status exam if indicated;
  • If there are injuries, (present or past) describe type, color, texture, size, and location;
  • Use a body map and/or photographs to supplement written description;
  • Obtain a consent form prior to photographing patient. Include a label and date.

Document laboratory and other diagnostic procedures:

  • Record the results of any lab tests, x-rays, or other diagnostic procedures and their relationship to the current or past abuse. Document results of assessment, intervention and referral:
    • Record information pertaining to the patient's health and safety assessment including your assessment of potential for serious harm, suicide and health impact of IPV/DV;
    • Document referrals made and options discussed;
    • Document follow-up arrangements.

If patient does not disclose IPV/DV victimization:

  • Document that assessment was conducted and that the patient did not disclose abuse;
  • If you suspect abuse, document your reasons for concerns: i.e. "physical findings are not congruent with history or description," "patient presents with indications of abuse".

At least one follow-up appointment (or referral) with a healthcare provider, social worker or IPV/DV advocate should be offered after disclosure of current or past abuse:

  • "If you like, we can set up a follow-up appointment (or referral) to discuss this further"; "
  • Is there a number or address that is safe to use to contact you?";
  • "Are there days/hours when we can reach you alone?";
  • "Is it safe for us to make an appointment reminder call?".

At every follow up visit with patients currently in abusive relationships:

  • Review the medical record and ask about current and past episodes of IPV/DV;
  • Communicate concern and assess both safety and coping or survival strategies:
    • "I am still concerned for your health and safety"
    • "Have you sought counseling, a support group or other assistance?"
    • "Has there been any escalation in the severity or frequency of the abuse?"
    • "Have you developed or used a safety plan?"
    • "Told any family or friends about the abuse?"
    • "Have you talked with your children about the abuse and what to do to stay safe?"
  • Reiterate options to the patient (individual safety planning, talking with friends or family, advocacy services and support groups, transitional/temporary housing, etc.).

RADAR A simple method for remembering the basics of the Guidelines is to use the RADAR method of inquiry and assessment for IPV/DV. RADAR is a mnemonic: R=Routinely screen female patients; A=Ask direct questions; D=Document your findings; A=Assess patient safety; R=Review options and referrals.

Figure 1. RADAR Intervention Method

R = Routinely Screen Female Patients

Although many women who are victims of IPV/DV will not volunteer any information, they will discuss it if asked simple, direct questions in a nonjudgmental way and in a confidential setting. Interview the patient alone.

A = Ask Direct Questions

  • "Because violence is so common in many women's lives, I've begun to ask about it routinely."
  • "Are you in a relationship in which you have been physically hurt or threatened?" If no, "Have you even been?"
  • "Have you ever been hit, kicked or punched by your partner?"
  • "Do you feel safe at home?"
  • "I notice you have a number of bruises; did someone do this to you?"

  • If the patient answers "yes": Encourage her to talk about it: "Would you like to talk about what has happened to you?" "How do you feel about it?" "What would you like to do about this?"

    Listen nonjudgmentally. This serves both to begin the healing process for the woman and to give you an idea of what kind of referrals she may need. Often a battered woman believes her abuser's negative messages about her. She may feel responsible, ashamed, inadequate and afraid she will be judged by you.

  • Validate her experience. Make sure she knows she is not alone. Millions of women of every age, race, and religion face abuse, and many women find it extremely difficult to deal with the violence. Emphasize that when she wants help, it is available. Let her know that domestic violence tends to get worse and become more frequent with time and that it rarely goes away on its own. "You are not alone." "You do not deserve to be treated this way." "Help is available to you."

    Tell her the abuse is not her fault. Explain that physical violence in a relationship is never acceptable. There's no excuse for it - not alcohol or drugs, financial pressure, depression, jealousy or any behavior of hers. "No one has to live with violence." "You are not to blame." "What happened to you is a crime."

  • If the patient answers "no", or will not discuss the topic: Be aware for any clinical signs that may indicate abuse: injury to the head, neck, torso, breasts, abdomen or genitals; bilateral or multiple injuries; delay between onset of injury and seeking treatment; explanation by the patient which is inconsistent with the type of injury; any injury during pregnancy, especially to abdomen or breasts; prior history of trauma; chronic pain symptoms for which no etiology is apparent; psychological distress such as depression, suicidal idealation, anxiety and/or sleep disorders; a partner who seems overly protective or who will not leave the woman's side.

    If any one of these clinical signs are present, ask more specific questions. Make sure she is alone. "It looks as though someone may have hurt you. Can you tell me how it happened?" "Sometimes when people feel the way you do, it may be because they are being hurt at home. Is this happening to you?"

D = Document Your Findings

Record a description of the abuse as she has described it to you. Use statements such as "the patient states she was . . . "If she give the specific name of the assailant, sue it in your record. "She says her boyfriend John Smith struck her . . ." Record all pertinent physical findings. Use a body map to supplement the written record. Offer to photograph injuries. When serious injury or sexual abuse is detected, preserve all physical evidence. Document an opinion if the injures were inconsistent with the patient's explanation.

A = Assess Patient Safety

Before she leaves the medical setting, find out if she is afraid to go home. Has there been an increase in frequency or severity of violence? Have there been threats of homicide or suicide? Have there been threats to her children? Is there a gun present?

R = Review Options and Referrals

If the patient is in imminent danger, find out if there is someone with whom she can stay. Does she need immediate access to a shelter? Offer her the opportunity of a private phone to make a call. If she does not need immediate assistance, offer information about hotlines and resources in the community. (Resources for Domestic Violence in Kentucky can be found in the "Resource" section near the end of this course).

Remember that it may be dangerous for the woman to have these in her possession. Do not insist that she take them. Make a follow-up appointment to see her or some other method of checking in.

 

Continue on to Safety Planning