10 tips for documenting domestic violence
Linda Lentz MA, RN

September 2010 
Volume 40  Number 9
Pages 53 - 55
  PDF Version Available!

DOMESTIC VIOLENCE AFFECTS both women and men of all ages. In the United States, approximately 1.3 million women and 835,000 men are physically assaulted by an intimate partner each year.1The 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. Your documentation contains information that may be useful in subsequent legal proceedings, but barriers to good documentation may weaken the impact of medical records in court. Reasons that domestic violence may be poorly documented include healthcare providers who are: * concerned about confidentiality and potential liability exposure. * concerned about recording information that might inadvertently harm the victim. * confused about how to use language to describe domestic violence injuries. * fearful of being "drawn into a situation" and having to testify in court. * unable to access useful information about assessing domestic violence.This article will help you improve your documentation skills when you encounter any patient who could be a victim of domestic violence.When documenting signs of potential domestic violence, follow these 10 guidelines.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, such as abrasions, ecchymoses, bites, and fractures. Use 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 your patient's

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