AUTHORS

Brian L. Springer, MD, FACEP, Wright State University Boonshoft School of Medicine Department of Emergency Medicine, Kettering, OH

Jared Brown, MD, Wright State University Boonshoft School of Medicine Department of Emergency Medicine, Kettering, OH

PEER REVIEWER

Ralph Riviello, MD, MS, FACEP, Department of Emergency Medicine, Drexel University, Philadelphia, PA

When screening for IPV, it is important to recognize and address any comorbid conditions the patient may have. A patient should be screened for these conditions after admitting that he or she is a victim. In cases in which the victim is not forthcoming, screening and intervention for comorbid conditions allows for continued interaction with healthcare providers and provides different avenues by which to address IPV concerns. Studies show that domestic violence victims have higher rates of psychiatric and mood conditions, such as anxiety, depression, PTSD, sleep disorders, eating disorders, and drug or alcohol abuse. Suicidality and suicide attempt rates were also much higher in abused women compared to the general population.7,10,11,12,49 If a patient screens positive for IPV, he or she should be screened concurrently for mental health and substance abuse. The screening process should include a referral process to appropriate agencies and linkage to available services. These additional steps are essential in treating the whole person and enhancing the odds of an effective intervention.

More studies are needed to understand how providers can better screen for IPV. Many women and men turn to EDs, clinics, and medical practices following IPV. Whether or not a victim self-identifies, providers must remain vigilant to recognize signs of domestic violence. Signs can be subtle, but early identification is necessary to help reduce the personal and societal effects of abuse.

Documentation

Identifying IPV is arguably the most important step in the ED; however, this is only the beginning of the pathway to finding help for victims. Documentation of IPV plays a central role and is critical to ensure the patient is treated adequately beyond his or her hospital stay and to ensure medicolegal protection of the provider. It is essential that healthcare providers understand what should be included in a complete domestic violence medical record.

There are many ways that providers are failing in this realm, and we need to understand the gravity of the situation. Unfortunately, documentation of IPV notoriously is done poorly. For one, the documentation threshold for domestic violence and IPV remains too high, and providers hesitate to code for it despite convincing reports and injury patterns.50 Using terms such as “domestic violence” and “intimate partner violence” carry a weight that “ecchymosis” or “fracture” do not carry, and this can lead to avoidance of the true diagnosis. At a minimum, if a screening tool shows positive results for violence, there should be some mention of this in a patient’s chart. Surprisingly, one study found that more than 10% of positive screenings for IPV showed no further documentation to address these concerns when reviewing charts.51 Emergency physicians and other healthcare providers also tend to chart injury-based diagnoses (e.g., fracture, post-traumatic headache, hematoma) more readily than to place assault or the even more descript “domestic violence” in a chart.50 As electronic medical records have grown in prevalence, simple things such as legibility of notes have improved, but historically a poorly hand-written note has been enough to make a record inadmissible in court.52

Although the main goal of documentation is better patient care, thorough documentation concurrently protects providers. If a provider is called as a witness in a domestic violence case, charted notes may be the only memory a provider carries of the event. Documentation also outlines the services provided to the patient. This includes proof of mandatory reporting, if required, as well as documentation of the resources and interventions provided to patients. Clear documentation also can help in the identification of domestic violence as providers review past records and can see trends in a patient’s medical history.

For victims of IPV, unbiased factual reports are the crux of any legal case. A well-documented ED visit can help to corroborate police reports and give testimony in a patient’s case. Although police often are involved, providers should not be dissuaded from thorough documentation under the assumption that police will handle all legal matters. Unfortunately, this is a commonly believed fallacy and has been shown to lead providers to document less when police are involved.50,52 Police and medical interactions often occur immediately following traumatic abuse, giving more weight to their assessments. Once wounds have healed and bruises have faded, a documented description of injuries may be all a victim has during legal hearings. When combined with police reports, a well-documented chart can serve as a vital tool for victims and prosecutors. Some patients may not choose to use this information immediately if they do not plan to press charges, but it is important they know the documentation will always be available in their medical records. Unbiased testimonies provided through medical documentation give patients a voice in the future and allow providers to continue caring for patients long after they are discharged.

As physicians create documentation in IPV cases, it is important to remember the central goal: objective factual documentation. This is best done by providing a clear and accurate timeline, using direct quotations, documenting mood and affect, and including a combination of both written and photographic evidence. First, as with any history and physical, there should be a clear timeline of events. For IPV in particular, it is important to include not only the events that led to the visit, but also a timeline of abuse if it has been an ongoing issue.53 Another simple way to document a patient’s history is by using direct statements from the patient. Phrases such as “my boyfriend held me against the wall” carry more weight when they are documented as direct quotes from the patient. Addressing the assailant’s relationship and actions allows no room for misinterpretation when they are in the patient’s voice. Immediately following a traumatic event, details about what occurred may be clearer, and the patient is more likely to make spontaneous exclamations about the stressful event. Words said in response to a triggering event can fill the legal requirement for “excited utterances.” These are statements made acutely following traumatic events and are admissible in court even months afterward because of the weight they carry.52

It is important to avoid language that could cast doubt on a patient’s credibility. This includes commonly used statements such as “alleged” or “the patient claims.” If such words are used, there should be justification for why one might doubt the patient’s story.50,53 Whenever possible, a complete chart should include pictorial representation in addition to the written documentation. Ideally this should be with photographs to provide concrete evidence of the bruises and wounds that may have healed before legal proceedings. A body map, available on several electronic records and paper-based template charts, is a valuable resource if cameras and photos cannot be linked to a chart. Written documentation is critical, but many times a picture is worth a thousand words, especially in court.52,53

Medical decision-making should include management beyond care for the patient’s physical injuries. It should discuss if mandatory reporting was initiated, as well as provide clear evidence of resources provided, referrals, and safe disposition planning. In these ways, medical providers can protect themselves and their patients effectively while creating a forensically useful chart.

Disposition and Safety Planning

After treating a victim’s medical needs, it is important to ensure a safe disposition, whether the patient will be discharged or admitted for his or her injuries. This often is managed poorly in practice because busy providers frequently lack the resources and time to address the patient’s needs fully. Studies suggest that concerns about safe discharge planning may be one factor that deters providers from screening for IPV. This stems from the worry that they will not be able to treat the patient adequately if the screening is positive.36,54,55 A large part of this is the fear of discharging a patient back into a dangerous environment without effective resources. Although clear guidelines are not established about what is most helpful to discharge IPV victims safely, a few overarching themes can help guide management. These include mortality risk assessments, safety planning, a diverse referral basis, and a team-based approach. These elements ensure that all aspects of a patient’s care are covered in a thorough and time-efficient manner in high-turnover emergency rooms.

Traumatically injured patients or those with clear acute medical pathology tend to be more straightforward admissions; however, a dilemma arises for patients who might be discharged and returning to a dangerous or even potentially lethal environment. If a patient feels safe to leave but the provider still has reservations, this can create conflict and further complicate management. In these situations, there are multiple sources urging the use of brief standardized questionnaires to assess mortality/lethality risk of discharging victims.

One study looked at multiple questions to assess such risk and narrowed them to five primary questions that increase the chance of recurrent near-fatal trauma.56 The study recommends that any patient who answers “yes” to three of five questions be labeled as high risk. (See Table 4.) The questionnaire had a sensitivity of 83% in identifying those who would have return ED visits with near-fatal injuries. Although not specifically addressed in the study, another factor to consider is the physical presence of firearms in the home. As noted earlier, the presence of a firearm in the home increases the risk of homicide significantly, and providers need to address if there are legal grounds for having firearms removed before allowing a victim to return home.35,17

Table 4. Example Mortality Risk Assessment Tool

Three of five affirmative answers are concerning for high risk of near fatal recurrent abuse.

1. Has the frequency or severity of physical violence increased over the last six months?

2. Has the abuser ever used a weapon or threatened you with a weapon?

3. Do you believe the person is capable of killing you?

4. Has the abuser ever beaten you while you were pregnant?

5. Is the person violently and constantly jealous of you?

Source: Adapted from Snider C, Webster D, O’Sullivan CS, Campbell J. Intimate partner violence: Development of a brief risk assessment for the emergency department. Acad Emerg Med 2009;16:1208-1216.

An example of a useful screening tool is the Danger Assessment Tool, developed in 1986 by Dr. Jacquelyn Campbell in consultation with IPV victims, shelter workers, law enforcement officials, and other clinical experts. Using a calendar to pinpoint abuse frequency during the past year, along with a 20-item questionnaire, the screening accurately identifies IPV victims at risk for death.57,58 Law enforcement, social workers, and healthcare providers all can obtain certification to use the screening.

For patients who are unable to be discharged, some medical centers have availability for admission; otherwise, patients may require referrals to shelters or alternative housing through a social worker.2

For patients who will be returning home, a personal safety plan is essential for continued empowerment and support. Safety plans take many forms and must be molded to each individual’s needs depending on the type of abuse, presence of children, cohabitation, patient’s coping mechanisms, and the available support systems. At a minimum, a safety plan should include emergency contacts, a plan if violence returns, a plan for leaving (to include finances, housing, and resource access), and involvement of family or friends. Ideally, these should be written plans to provide a useable guideline if the person needs to take action when abuse returns. Thinking clearly in the midst of a significant stressor such as abuse can be difficult, and a pre-formulated safety and response plan can bring clarity during those stress-laden times. Safety planning responsibilities often can fall on social workers, but in smaller EDs this may need to be addressed by physicians, nurses, or other healthcare providers. The National Domestic Violence Hotline website has multiple suggestions for victims working to establish a safety plan, and is a valuable resource that providers can give to their patients.59

Beyond safety planning and in-hospital interventions, IPV victims have many needs that must be addressed in their recovery. This is where effective referrals come into play. Referrals fall into multiple categories, including other medical providers, social workers, mental health and substance abuse counseling, housing and shelters, law enforcement, legal counseling, spiritual counseling, financial counseling, and education. Resource needs and availability differ from patient to patient. There is no consensus on the most effective referrals in a victim’s recovery, but there is agreement that a multifaceted approach is needed.25,60 At a minimum, a brief psychiatric evaluation should be performed with referrals placed if needed, substance abuse screening and resources offered, child protective services called if children are present in the home, legal and police services offered, and housing information given if there is an immediate safety risk. Beyond provider referrals, brochures and printed materials can be helpful, but patients also should be referred to online resources such as the National Domestic Violence Hotline.59 Small details can fall through the cracks easily, so having standardized intake sheets can help minimize errors.

As with safety planning, responsibility for disposition planning varies, and many strategies are used. Nursing staff often help with screening and can aid in resource referrals. Social workers or even specialized IPV teams also can allow the physician to offload responsibility, thereby helping overall patient flow.2

Conclusion

Ultimately, physicians need to be sure an adequate evaluation has been performed and an appropriate plan is in place. Through using mortality risk assessment tools, safety planning, a broad resource referral basis, and a team-based approach, healthcare professionals can provide the initial framework for a victim’s continued recovery. A brief ED stay rarely will resolve an IPV victim’s underlying situation, but if done effectively, safe discharge planning and referrals can start the recovery process.

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