Domestic violence: the general practitioner's role
Document
Accurate documentation, over time at successive consultations,
may provide cumulative evidence of abuse, and is essential for use
as evidence in court, should the need arise (Edwards, 1997).
Record clearly:
- Data from previous medical record which is suggestive of prior
abuse.
- Time, date and place and witnesses to assault or accident.
- If patient states that abuse is the cause of injury, preface
patient's explanation by writing: "Patient states . . . ".
- Avoid subjective data that might be used against the patient
(for example, "It was my fault he hit me because I didn't have the
kids in bed on time.").
- If patient denies being assaulted, write: "The patient's
explanation of the injuries is inconsistent with physical findings"
and/or "The injuries are suggestive of battering."
- Record size, pattern, age, description and location of all
injuries. A record of "Multiple contusions and lacerations" will
not convey a clear picture to a judge or jury, but "Contusions and
lacerations of the throat" will back up allegations of attempted
strangling. If possible, make a body map of injuries. Include signs
of sexual abuse.
- Record non-bodily evidence of abuse, such as torn
clothing.