8. Documenting IPV in Patients Records

The following documentation is recommended for all patients assessed to be in an abusive relationship with an intimate partner:

  • Take a history of the IPV including:
    • Current and past incidents of abuse, including specific dates and times of precipitating events that lead patient to seek medical care
    • Patient’s injuries or other health conditions associated with IPV (e.g. high blood pressure, anxiety, STIs, miscarriage)
    • A Body Map to describe external injuries
    • Perpetrator’s name, address and relationship to the patient, if possible
    • Quoted statements from the patient about the abuse using her or his own words (e.g. Patient stated “My boyfriend punched me in the chest and pushed me down the stairs” rather than summarizing the incident or using legal terms like “domestic violence” or “alleged perpetrator”.)
    • Patient’s demeanor, such as patient was crying, trembling, angry, upset, calm, etc.
  • Collect evidentiary materials when possible including:
    • Photos of injuries, when patient signs a consent form (one full-body photo to identify patient, one photo of the region where injuries are located and close-ups of all wounds)
    • Clothes or other possessions damaged during abusive incident that could be used by prosecutors in court
  • Describe interventions, such as:
    • Provided patient with a Safety Plan Checklist and/or a Safety Card with information about IPV
    • Educated patient about IPV and its potential health implications
    • referrals to local IPV services and/or internal social service department
    • Information about obtaining an order of protection
    • Asked patient if she or he wanted to call the police

“Documenting Domestic Violence: How Health Care Providers Can Help Victims” produced by the U.S. Department of Justice provides guidance to medical providers on how to increase the success of IPV prosecution without appearing in court. http://www.ncjrs.gov/pdffiles1/nij/188564.pdf