In Indiana, everyone has a duty to report child abuse or endangered adult abuse, but the state has no requirement to report domestic violence. If you suspect a patient is a victim of abuse, you can typically file a report with the police only if the patient consents. However, without patient consent, you can still help by taking these steps.
Good documentation in a patient’s medical record is often the only evidence of abuse. Importantly, documentation can help a victim obtain custody of children and secure protective orders. Documentation also can be used in lieu of testimony.
“Detailed documentation is one of the most important things a physician can do to help a patient,” noted Rhonda Sharp, M.D., chair of the ISMA Family Violence Committee. “Medical records are often not admissible in court because they lack details of injuries, quotations from the patient or a description of the patient’s demeanor.”
According to Physicians for a Violence-Free Society, effective documentation should include:
- Quotations from the patient
- Body charts, injury maps
Any notations in the medical record should be specific and detailed, and include names, locations and witnesses. The ISMA offers a body diagram to help you record injuries. Find the free form on the ISMA website.
Offering safety information to identified victims is crucial. The ISMA makes available business-sized cards that provide a safety plan as well as a list of local shelters and programs. The resource cards are small and can be hidden for further safety of the patient.
“Referring a patient to a shelter – just as you would a specialist for treatment of any other physical condition – helps a patient know they are not alone,” explained Dr. Sharp. “Patients may feel reassurance knowing there are other services that can help them, and doctors feel like they are getting their patient much-needed assistance.”
The ISMA offers you additional resources here.
Also, the Indiana Coalition Against Domestic Violence has helpful brochures free for download on the ICDAV website. Or order hard copies by calling (317) 917-3685; mention you are an ISMA member.