Violence Against Women: A Site Dedicated to Providing Information and Resources for Health Care Providers & Survivors of Violence against Women Violence against Women
A site dedicated to providing information and resources for health care providers as well as survivors of violence

Health Care Providers > Role of Health Professionals > Documentation

Importance of Documentation

Documentation in cases of violence is an area in which health care providers are required to play a very vital role as this provides critical (and several times the only) evidence of violence, which can be of tremendous use to the woman if she decides to access the legal system. Every woman who reports injury caused by violence is meant to be registered as a medico-legal case (MLC). Public hospitals have an MLC register in the casualty department, in which all medico-legal cases must be recorded. While doing the documentation, inform the woman that whatever you document in the hospital can be used by her in a court of law. Medical documentation can corroborate police data. It constitutes unbiased, factual information recorded shortly after the abuse occurs, when recall is easier.

The history that you elicit from the woman should be documented in her words in the MLC register as well as the case paper. It should include details of resulting injury/injuries and of the violence episode (such as location of incident, relationship to abuser, severity and frequency of earlier episodes of violence, and other health consequences not apparent at the time of the medical visit). All these details along with the findings in examination should be recorded in the MLC register as well as on the case paper.

Even if you do not work in Casualty, should you come across any abused woman in the OPD or in the wards, please document the history in her Indoor/OPD papers and refer her to Casualty to get an MLC recorded.

Under the Protection of Women from Domestic Violence Act, 2005, you have to record a domestic incident report and forward it to the protection officer in that area if this has not already been done. You cannot, under any circumstances, refuse treatment to an abused woman and are required to give her a medical report free of cost.

A sample of an ideal MLC documentation has been shown below :

 




 


Events | News Updates | Forum | Contact Us Violence Against Women: A Site Dedicated to Providing Information and Resources for Health Care Providers & Survivors of Violence against Women Violence against Women CEHAT is a research centre of Anusandhan Trust. We are involved in research, training, service and advocacy on a variety of public health issues. © 2017 CEHAT. All Rights Reserved - Website Design and Development by Wordcraft. This website is best viewed at Screen Resolution 800x600 and Text Size Medium, IE 5+