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Thorough documentation of the nature and severity of the injuries as well as any statements made by the woman about the perpetrator, time, date, location of the event are important legal details that may be used at a later date in civil or criminal proceedings. Proper documentation can make the difference between getting a conviction or the abuser going free, between a woman being convicted of murder or your documentation helping to prove she was acting in self-defence, as well as in custody/access actions involving vulnerable children. And medical documentation of a doctor's or nurse's suspicions of abuse, even if denied by the patient, will be important observations that could alert a subsequent nurse or doctor to the possible presence of wife abuse if the woman displays suspicious injuries or symptoms at some future date.
Essential Points to Document
- Location and severity injuries, both past and present. Use a body map (next page) to indicate where on the patient's body each injury or area of tenderness is located. Take photographs of the woman's injuries.
- The woman's account of the incident.
- The abuser's name or names (there may be more than one).
- Details of previous violent contacts the abuser has had with the patient.
- Police information (i.e., police officer's name, identification number), if relevant.
- Telephone numbers where the patient may be reached, or the telephone number of a close friend or relative who would be able to contact her.
- Emotional as well as physical symptoms.
- Any additional non-physical indications of abuse, such as torn or damaged clothing.
- The whereabouts and safety of the patient's children.
In taking the photographs, there are some specific and detailed procedures to follow:
- Discuss the fact that the photographs will be important legal evidence. (Even if she is not considering criminal or civil action now, she may at a later date.)
- Obtain her written consent to take the photographs and keep the signed consent on file.
- Try to ensure that her face or hand with a ring on it appears in as many pictures as possible.
- Use a scale such as a small ruler or a coin to provide verification of the size of the injury.
- After the photographs are taken, write the following information on the back of each of them:
- the name of the woman
- the date and time the photograph was taken
- where it was taken
- who took it and who else was present in the room, if anyone.
- It is preferable to take two sets of pictures, so you can offer one set to the patient. Place the other set in an envelope, seal it and write the following across the seal:
- the date
- who sealed the envelope
- what is contained in the envelope.
- Put the envelope in a file that is not accessible to the public. Do not open the envelope unless the woman requests it.
If you as the doctor or nurse are suspicious of wife abuse but the patient denies it, it is still important to document your suspicions. If possible, documentation should list the factors you based your suspicions on. Record that the patient's explanation of injuries was not supported by the physical examination. To provide a full and accurate record for each case in which domestic violence has been reported by the patient, be certain to:
- Specify "domestic violence" as part of the diagnosis note in the hospital record
- Use wording such as "the patient states ... ", "injuries are consistent with ... " when describing the situation.
Collecting Forensic Evidence
If the patient has decided to take legal action against the abuser, evidence related to the assault must be collected, labeled, and handled to ensure that it is useful to the patient's case. When specific questions arise concerning handling and collecting forensic evidence, the attending police officer should be consulted concerning the specific protocol to follow for such material. If the patient is unsure about taking legal action at the time, encourage her to allow the collection of forensic evidence in case she changes her mind later on.
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