DOCUMENTATION

To provide a full and accurate record for each case in which FDV has been reported by the patient, be certain to:

• Specify family and domestic violence as part of the note in the hospital record or departmental file and data base;

• Use wording such as "the patient states…" when describing the situation.

If abuse is suspected but denied:

• Record that the patient’s explanation of injuries was not supported by the physical examination.

Essential points to document:

• The whereabouts and safety of the children, if any;

• The alleged abuser’s name or names (there may be more than one);

• The location and severity of injury, use a body map as a clinical aide if appropriate;

• Dates and times when abuse occurred, if know;

• Previous violent episodes;

• Contact information for the survivor and close friends who could act as an intermediary; and

• Emotional as well as physical symptoms.

Forensic evidence pertaining to legal action requires careful collection, labeling and handling to ensure that it is useful to any court action taken by the survivor. As reporting violence against an adult to the police would be done with the knowledge and consent of the survivor, specific questions in relation to the handling and collecting of forensic evidence requires consultation with the attending police officer.

If the survivor is unsure about taking legal action at the time, encourage a full disclosure regarding evidence so this may be documented in case she changes her mind later on.

(Taken from Hotch, D. Grunfeld, A. Mackay, K. Cowan, L. 1995 Domestic Violence Intervention By Emergency Department Staff, Family Violence Prevention Division, Health Canada)

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© Health Department of Western Australia. All rights reserved.
Last Updated: Friday, 20 March 1998 10:28