Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
• Gynecological problems (genital lacerations and contusions, sexually transmitted infections, including HIV/AIDS, rapid repeat pregnancies). • Medical signs and symptoms such as headache, chest pain, abdominal pain, pelvic pain, fatigue, eating disorders, or functional gastrointestinal disorders. • Localized or generalized neurological findings such as altered mental status, seizures, motor or sensory deficits, and memory problems. • Behavioral/psychiatric signs such as anxiety, depression, panic, suicidal ideation or attempt, substance abuse • Social “red flags” such as frequent missed appointments, or non-adherence to prescriptions or medical instructions. • Partner “red flags” such as excessively attentive or jealous behavior on the part of a companion, a partner who insists on accompanying a patient during examinations, or a partner who speaks for the patient or displays dominant behaviors. • Delay between onset of injury and presentation for care. • New diagnoses of sexually transmitted infections may also result from sexual assault in an IPV relationship If any of these signs and symptoms are suspected to be the result of IPV, additional and more thorough questioning is warranted [5]. BEHAVIORAL SIGNS OF IPV Even in the absence of disclosure, patients may appear fright- ened, ashamed, embarrassed, defiant, or even overtly angry. Basic questions on the medical history may be answered in a manner that appears ambiguous or evasive. Other behavioral clues may include: • Partner accompanies the patient to clinical visit, insists on staying close, and speaks for the patient, answering questions or monitoring/controlling the patient’s responses. • The patient appears reluctant to speak independently or to disagree with partner. • Intense irrational jealousy or possessiveness expressed by partner or reported by patient. • Patient and/or partner deny, minimize, or divert questions about medical problems or injuries.
• Patient displays an exaggerated sense of personal responsibility for the relationship, including self blame for partner’s violence or for staying in the relationship. • Explanations that are inconsistent with observed illness or injury pattern. DOCUMENTING IPV Documentation in the medical record can provide valuable information if your patient seeks legal redress for abuse, as well as being the basis for optimal medical care. Even if the patient does not intend to take action now, the records may be needed later, for instance, in child custody proceedings. As vigorous criminal prosecution of intimate partner assault increases, accurate and legible medical records can often substitute for a physician’s personal testimony in court. Some electronic medical record systems (EMRs) have templates to facilitate IPV screening and/or sexual assault documenta- tion. Robust EMRs include prompts to remind providers to screen, and include links for inquiry and documentation formatting, lethality assessment questions, safety plan tips, and local resources. Additionally, for reasons of safety and confidentially, these systems have documentation and listing of IPV specifically excluded from clinical visit summaries, billing statements, and electronic health portals. One example is the Kaiser Permanente Systems Model approach [28; 29]. Many EMRs are currently used nationwide, resulting in wide variances in the use of prompted IPV screening. Whether using an EMR or not, clinicians should document findings carefully and non-judgmentally. Drawings or labeled photo- graphs may supplement a written description. It is important to describe the patient’s symptoms and signs accurately and to indicate “intimate partner violence” as a diagnosis or problem if appropriate. DOCUMENTATION DETAILS Records should be kept in a precise, professional manner, and should include the following:
For patients with acute physical injuries: a. Date and time of visit (if scheduled
appointment) or arrival (if in the emergency department). b. Contact information for anyone accompanying the survivor. c. Chief complaint and description of the event, using the patient’s own words in quotation marks whenever possible rather than the physician’s assessment. For example, “My husband hit me with his fist on _____ date at _____ time” is preferable to “Patient has been abused,” “Patient hit with a fist,” or “Patient alleges/claims she was hit.” d. Include the partner’s name in the record if possible.
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MDFL0627
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