ASSESSMENT, DOCUMENTATION, AND TREATMENT

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:

  • Poor physical health
  • Depression and/or anxiety
  • Trauma and posttraumatic stress disorder
  • Feelings of guilt or shame
  • Increased substance abuse
  • Cardiac symptoms such as hypertension and chest pain
  • Chronic disorders and chronic pain
  • Gastrointestinal problems due to stress
  • Reproductive problems
  • Unsafe sexual behavior
  • Low self-esteem
  • Self-harm and suicide
  • Inability to trust others
  • Difficulty maintaining a job
    (ACOS, 2022)

Physical injuries associated with IPV are frequently identified as craniofacial or on the upper extremities and involve soft tissue or fractured bones. Multiple injuries, patterned injuries, and spinal cord injuries can also be emblematic of physical abuse. It is important for providers to be alert to the possibility of IPV when treating such injuries (Sun et al., 2023).

LACK OF PHYSICAL INJURY

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.

According to the National Center for Elder Abuse (n.d.), the most common signs and symptoms 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
STRANGULATION

Strangulation is one of the most lethal forms of domestic violence; unconsciousness may occur within 10 seconds and death within 4 minutes. Strangulation is also one of the best predictors for future homicide of victims of domestic violence. Although strangulation was long overlooked in medical literature, Florida statute 784.041 now defines strangulation as a felony crime and recognizes strangulation of an intimate partner, dating partner, or family member (defined as domestic battery by strangulation) as a felony (Online Sunshine, 2023a).

While victims of strangulation may have no visible injuries, the lack of oxygen during the assault can cause serious trauma to the brain and lead to death days, or even weeks, later. Strangulation can have a devastating psychological effect on victims in addition to a potentially fatal outcome, including death by suicide.

Signs and symptoms indicating possible strangulation include:

  • Neck or throat pain
  • Discomfort or difficulty swallowing or talking
  • Vocal changes
  • Shortness of breath
  • Loss of consciousness
  • Memory loss
  • Dizziness
  • Feeling faint
  • Blurry vision
  • Involuntary urination or defecation
  • Tinnitus
  • Linear abrasions
  • Bruising on the upper neck, chin, or face
  • Subconjunctival hemorrhage
  • Conjunctivae petechia
  • Neck swelling
  • Neck tenderness upon palpation
    (McCarthy, 2020)

(See also “Resources” at the end of this course.)

DANGER ASSESSMENT INSTRUMENT

The Danger Assessment Instrument is an excellent tool and has been used for over 25 years by health professionals, law enforcement, and advocates. The current version of this tool consists of 20 questions that the client may respond to with yes/no answers. The various questions are weighted for risk factors associated with intimate partner homicide. Some of the risk factors include past death threats, partner’s employment status, and partner’s access to a gun.

Culturally sensitive versions are now available to evaluate same-sex and immigrant relationships for lethality. The tool, including the abbreviated version (DA-5), is available online for certified professionals to download after they have completed a brief online training and post-test (Alliance for Hope, 2019).

(See also “Resources” at the end of this course.)

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. Asks the patient to 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)
TRAUMA-INFORMED PRACTICE

When evaluating a patient who has potentially experienced a traumatic event, it is important to implement trauma-informed practices. Since a patient’s history is unknown to the provider unless they have made a disclosure, it is best practice to always conduct exams in a trauma-informed manner and provide an environment of healing-centered engagement. The goals of trauma-informed care are to promote resilience and provide hope for healing.

The five guiding principles of trauma-informed practice are:

  • Safety: Assurance of emotional and physical safety is of the utmost importance.
  • Trustworthiness: The clinician must present clear boundaries and earn the patient’s trust so that they feel safe enough to make disclosures.
  • Choice: The patient must be given the ability to make active choices and have a sense of control over the environment.
  • Collaboration: The relationship between the patient and provider is collaborative and individualized.
  • Empowerment: The provider’s approach helps the patient discover and implement their strengths.

(Integrative Life Center, 2021)

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.

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, and the Department of Family and Child Services offers a form online for digital or faxed reports (see “Resources” at the end of this course).

DO’S AND DON’T’S OF DOCUMENTATION

Do

  • Print or type legibly.
  • Fill out forms completely.
  • Document the time and date that the exam was done.
  • Write down the name of the person who provided the history.
  • Record statements exactly as they are given and by whom.
  • Use quotation marks to document what the patient or caregiver said.
  • If a copy is made, make sure it is complete, legible, and no parts are cut off.
  • Rather than leaving a section blank, write “not done.”
  • Include your signature on each page.
  • Complete any forms that are required by law.

Don’t

  • Don’t leave sections of the form blank.
  • Don’t use correction fluid to make corrections.
  • Don’t use abbreviations.
  • Don’t write your own conclusions about findings.
  • Don’t use legal terms such as battery or assault.
  • Don’t complete the form if you did not collect the information yourself.

(SAFEta.org, 2022)