This research brief provides techniques for healthcare providers to help aid victims during legal proceedings.
In order to achieve this goal, certain changes need to take place when documenting victims. Some of these changes include the following: (1) photographs of injuries should be taken if abuse is known or suspected; (2) reports by healthcare workers also need to be written legibly, since one of the biggest complainants about the medical profession is that healthcare providers tend to write illegibly; (3) when documenting patients’ own words they should be set off by quotation marks. If there is any discrepancy between the medical provider and the patient, an explanation should be provided; (4) records written by medical examiners should use only medical terms and avoid any legal ones; (5) medical professionals should also avoid conclusive terminology and making any reference to domestic violence; and (6) healthcare providers should not only observe and document a patient’s demeanor, but also include facts like time of day patient was examined and how much time has elapsed since the abuse allegedly occurred. These simple documentation changes can dramatically increase the usefulness of the information healthcare workers record and help their patients obtain legal remedies. Charts, tables, notes
Date Published: September 1, 2001
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