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 > How to document

What to remember when documenting

Some points to keep in mind when you are documenting cases of violence against women:

- Write legibly. It matters in the court of law

- Set off the patients own words or use such phrases  as patient states or patient reports.

- Indicate that the information recorded reflects the patients words.

- Avoid such phrases as: patient claims or patient alleges.

- If observations conflict with the patients statements, record the reason for the difference.

- Use medical terms and avoid legal terms such as: alleged perpetrator.

- Avoid summarizing a patients report of abuse in conclusive terms. If such language as patient is a battered
woman lacks sufficient accompanying factual information, it is inadmissible.

- Do not place the term domestic violence or abbreviations such as  in the diagnosis section of the medical record. Such terms  do not convey factual information and are not medical terminology.

- Record the time of examination & that of injury/ assault







Record body injuries with the aid of a body map  as shown in the diagram below


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