ASSESSMENT, DOCUMENTATION, AND REPORTING

Assessing for Signs and Symptoms

Every healthcare facility should screen patients routinely for potential domestic violence. The screening can be part of the intake interview or included as part of the written history. Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of any person who is accompanying them.

Healthcare professionals should be alert for signs and symptoms that may be related to domestic violence:

• Delay in seeking care or missed appointments
• Vague or inconsistent explanations of injuries or nonspecific somatic complaints
• Depression, chronic pain, and social isolation
• Substance abuse and use of alcohol or drugs
• Signs of abuse in pregnant clients (because abuse often escalates during pregnancy)
• Lack of eye contact and/or an intimate partner who is reluctant to leave the patient alone with the healthcare professional
• Patient who is fearful, anxious, withdrawn, angry, nonresponsive, or afraid to talk openly
• Suicide attempts

According to the National Center for Elder Abuse (2020), the most common physical findings of physical abuse among older adults include:

• Bruises, black eyes
• Contusions, welts, rope marks, or signs of being restrained
• Lacerations, wounds, punctures
• Dental problems, broken eyeglasses
• Head injuries, internal bleeding
• Fractures, sprains, dislocations
• Pressure ulcers, untreated injuries
• Chronic pain
• Sexually transmitted infections
• Poor nutrition/poor hydration
• Over or under-use of medications
• Sleep problems, sudden change of behavior
• Report of being hit
• Caregiver not allowing visitors to see the elder alone

PHYSICAL EXAMINATION

Following an established procedure to examine patients who may be victims of abuse will ensure that no critical information is overlooked. In some clinical settings, the best option may be to escort the patient to the emergency department to conduct an exam.

During the physical examination, the clinician:

1. Has the patient change into an exam gown that will allow all areas of the body to be examined
2. Checks for injuries over the entire body and especially the face, throat, neck, chest, abdomen, and genitals
3. Notes patterned injuries such as bruises that resemble teeth marks, hand prints, belts, or cords; observes burns that are consistent with cigarette tips
4. Notes any pain or tenderness on palpation
5. Documents physical findings in detail and includes measurements, preferably using a report form specified for domestic violence exams
6. Photographs injuries, including long-distance, mid-range, and close-up perspectives; photographs each injury with and without a scale
7. Conducts a mental status exam
8. In patients who report strangulation, considers the use of imaging to rule out life-threatening injuries
9. Uses open, nonjudgmental questions regarding the mechanism of injury
10. Does not cut clothing or discard any potential evidence; always collects, preserves, and maintains chain of custody; stores all evidence in paper bags, with wet evidence placed inside a waterproof container and given to law enforcement for immediate processing
    (CCFMTC, 2014; TISP, 2019)

NONPHYSICAL SIGNS

It is important to remember that many victims of domestic violence may show no physical signs of injury at all. Nonfatal strangulation, which is a strong predictor of future homicide, may leave no marks. Sexual assault may result in no visible trauma. In fact, there may be no physical signs resulting from the top five predictors of lethality: threatening to use a weapon, threatening to kill the victim, constant jealousy, strangulation, and forced sex.

Documenting Suspected Domestic Violence

Accurate, thorough documentation of the patient’s injuries is essential in cases of suspected abuse because it can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims obtain a restraining order or qualify for public housing, welfare, health and life insurance, and immigration relief.

Recommendations for documentation of suspected domestic violence include:

• With the patient’s permission, photograph the injuries whenever possible.
• Using a body map, document the location, number, type, and characteristics of injuries.
• Record the patient’s own words about how the injuries occurred, using quotation marks or prefaced by “the patient states” or “the patient reports” to indicate information that came directly from the patient rather than a third party; do not paraphrase.
• Describe the patient’s demeanor (e.g., crying, angry, agitated, upset) as well as the patient’s appearance.
• Identify the person whom the patient reports as the abuser and document the patient’s own words in quotes (e.g., “My boyfriend kicked me”).
• Include the time of day when the patient is examined and, if possible, how much time has elapsed since the injuries occurred, using the patient’s own words (e.g., “The patient states, ‘My husband punched me last night.’”).
• Use legible handwriting (if not documenting in an electronic record); poor handwriting on medical records can cause documentation to be deemed inadmissible as evidence.
• Do not include personal opinion or conclusions in the documentation. Document facts objectively so that others may draw their own conclusions.
• Do not use the terms domestic violence, DV, or intimate partner violence in the documentation. These are legal terms and are for the court to determine.
• Do not use other terms that have specific legal meanings (e.g., “patient alleges”).
• Document any reporting process that was followed per local or state protocol.
  (Lentz, 2011)

A documentation form for mandated reporters, although not required, is helpful to prompt the clinician to include all of the necessary information. A documentation form for that purpose may be provided by individual institutions.

Reporting Domestic Violence

Most states have laws pertaining to reporting suspected domestic abuse that healthcare professionals may encounter in the course of patient interactions. Reporting is typically required for suspected domestic violence and abuse involving children under 18 years of age (child abuse) or adults 18 years of age or older who are unable to protect themselves due to a disability (dependent adult abuse).

Conversely, in cases involving competent adults, healthcare professionals may be required to obtain informed consent before making a report. Otherwise, they may be prohibited to make a report in cases where the victim does not wish a report to be made. Such provisions allow adult victims to maintain control over their own lives and may make them more likely to ask for help and receive the information they need to stay safe (Currens, 2017).

Healthcare professionals may also be required by law in some states to assist victims by offering educational materials and contact information so that they may connect with local resources. This may include referrals to shelters or for legal assistance and information such as how to obtain a protective order. Since there may be a concern for a negative response if an abuser discovers educational materials and/or referral lists, it is recommended to provide a resource list in a discrete format (such as concealed in a small item that fits into a pocket or purse) for victims who may need it.

Laws pertaining to reporting domestic violence and abuse usually specify both legal consequences and legal protections for healthcare professionals who make a report. Typically, anyone acting upon reasonable cause or in good faith in making a report is given immunity from any civil or criminal liability. However, anyone knowingly or wantonly violating reporting laws, such as intentionally failing to make a required report or making a false report with malice, can be held criminally liable.

All healthcare professionals should keep themselves informed of mandatory reporting requirement laws in their jurisdiction as well as the current status of related statutes. Good communication with local law enforcement and judicial offices is helpful in order to stay abreast of any changes.