Medical documentation may be the only proof of domestic violence, when police reports are not filed. It can be used with or without collaborative police data by victims or their attorneys to secure a restraining order, to enlist supportive services, and to qualify to receive a number of resources such as public housing, welfare, health and life insurance, victim compensation and immigration relief. Medical documentation also provides national surveillance that ultimately determines federal funding for programs working to help DV victims.

Documenting DV involves photographing injuries or drawing body maps. It is important to include the patient’s face in photos, so personal identity cannot be contested. The time of the incident leading to injury, according to the victim, and the time of the medical exam should both be documented. Written notes must be clearly legible. Appropriate content includes specifics about what the victim says. The most useful are direct quotes and excited utterances that state who the speaker is. The name of the abuser as reported by the victim should be recorded.

Some words to avoid in documenting DV are those that imply doubt, such as ‘the patient claims’ or ‘alleges’, and qualifiers of the incident such as ‘apparent’ or ‘suspicious assault’. For surveillance tracking purposes it is useful to use words such as ‘domestic violence’ or ‘abuse’ along with the medical diagnosis.

Some nurses may be hesitant to document DV for fear of either unintentionally making things worse for a victim or they are uncertain about liability for violating professional confidentiality. Others may be fearful of being called to testify in court. While there is no way to know what the scenario will entail in an individual case of DV, negligence or improper documentation may inadvertently subvert a victim’s legal case against an abuser, adding to the overall problem.

Using words such as ‘claims’ or ‘suspicious’ are appropriate to include in documentation of patient assessment.

The U.S. Department of Justice website provides information for health care providers. Please access the site, and click on the first link "Click here for Enos/Isaac article entitled, "Documenting Domestic Violence: How Health Care Providers Can Help" (You'll be able to download it to your computer, and then open it with Acrobat Reader).

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