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Documentation if the explanation of injuries given is inappropriate or inconsistent with the injury pattern.
Sexual assault forensic documentation and evidence collection Documentary evidence of an attempted or completed rape can be collected up to five days after the crime occurs. Physical evidence that can be used for medical assessment and possible criminal prosecution should be obtained using a Sexual Assault Forensic Evidence (SAFE) kit, which can be found in most hospital emergency departments.Unless the patient is unwilling or unable to present to the emergency department, the examination and evidence collection should be conducted in the emergency setting. An increasing number of hospital emergency departments use the services of Sexual Assault Nurse Examiners (SANE nurses) who have specific training in forensic nursing, evidence collection, and crisis counseling. If a patient calls your office before presenting to the emergency department, he or she should be told to refrain from showering, bathing, or douching before arriving at the hospital. Victims of sexual assault should be instructed to put all clothes worn during the assault in a paper bag to bring to the hospital as additional evidence. Strategies for Improving Care for IPV Victims Effective Communication Strategies As important as it is to ask the right questions, it is equally important to refrain from asking questions in a manner that might frighten or intimidate your patient, increase the sense of humiliation and shame about the violence, or be interpreted as blaming the survivor for the situation. Here are some pitfalls to avoid: 30 • Do not inquire about abuse in the presence of the partner, friends, or family members. Children older than three should not be present while discussing IPV. • Discussing IPV can be very difficult and can leave patients feeling vulnerable. Do not inquire about abuse until the patient is fully clothed. • Do not break patient confidentiality by disclosing any information or discussing your concerns with the patient’s partner. • Most survivors do not identify themselves as abused because of the perception of shame and worthlessness associated with that term. Therefore, avoid using the words “victim,” “abused,” or “battered” when speaking with the survivor. Instead, use words like “hurt,” “frightened,” or “treated badly.” • Assure the survivor that everyone deserves to feel safe and no one deserves to be abused. Never ask your patient what they did to bring on the violence. • Do not ask your patient why they have not left their partner. • A survivor may leave a partner only to later return. If this is the case with your patient, avoid asking why they have returned.
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 documentation. 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 photographs 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. e. Complete medical history. f. Relevant social history. g. A detailed description of injuries and other relevant physical findings. Where applicable, the location and nature of injuries should be recorded on a body chart, drawing, or digital photograph. h. An opinion on whether the injuries were adequately explained or not.
j. Documentation that the physician asked the patient about IPV, together with the patient’s response. k. Results of pertinent laboratory and other diagnostic procedures. l. If the police were called, the name, badge number, and phone number of the investigating officer and any actions taken. m. Name of treating health care provider(s). The EMR can facilitate interviews and a template can be created to ensure all of the above pertinent information is obtained. Make sure the patient knows how to access their records, and also that the patient knows the document is confidential, thus requiring their permission or a subpoena for the partner or anyone else to view it. Documenting Abuse With Photographs In addition to complete written records, photographs can be of particular value as evidence. Additional imaging studies may be useful, depending on the clinical situation. The physician should obtain written consent for photographic documentation from the patient prior to taking photographs. Digital images should be dated and signed by the physician (freehand or electronic signature), and accompanied by a statement that indicates that the images are authentic and unaltered. documentation include: • Whenever possible, take photographs before medical treatment is provided. • Photograph from different angles, full body, and closeup. • Hold up a coin, ruler, or another easily identifiable object to illustrate the size of an injury. • Include a date marker on the photograph. If not available from within the camera, that day’s newspaper or other dated material may be used. • Include the patient’s face in at least one picture and some identifiable part of the patient in all photographs. • Take at least two pictures of every major trauma area. • Mark photographs precisely as soon as possible with the patient’s name, location of injury, names of the photographer and others present, and the date and time of the photograph. • To maintain chain of custody and confidentiality, be consistent as to where photographs are filed and who has responsibility for and access to photographs. • Arrange for the patient to return in two or three days for additional photographs to document the progression (and healing) of visible injuries. Techniques for optimal photographic
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