There exist a set of standards that provide guidance in all health care settings for policies and procedures to assess, document, and make referrals to address family violence, including intimate partner abuse, child abuse, and elder abuse.
It's surprising that this type of health care record is rarely provided by those seeking medical, psychological, or legal assistance. Yet, this type of record can provide the quickest help, direct resources to where they are needed the most, and provide the surest path to prevention, and yes, pathology prevention.
Violent experiences have significant immediate and long-term consequences. The most obvious immediate health care problem is injury, but an increase in annual health care cost may persist for up to 15 years after the violence ends. Traumatic brain injury, headaches, and pain are directly associated with the injury received; however, victims of abuse also have significantly more chronic health problems, including significantly more cardiovascular, endocrine, immune, and digestive problems. Women who are victims of abuse have more gynecologic problems and negative consequences during pregnancy (e.g., preterm birth, low-birth-weight babies, perinatal deaths).
Abuse during pregnancy is also a significant health problem, with serious consequences for both the pregnant mother (e.g., depression, substance abuse) and infant (e.g., low-birth weight, increased risk of child abuse).
Abuse victims have significantly more depression, suicidality, post-traumatic stress disorder, and problems with substance abuse. Rape survivors are three times more likely to use marijuana and six times more likely to use cocaine than nonvictims. Forced sex contributes to a host of reproductive health problems, chronic pelvic pain, unintended pregnancy, sexually transmitted infections, and urinary tract infections.
Child maltreatment can have deleterious effects on a child's quality of life and may lead to overall poor health, which can last into adulthood. Children who are abused have a higher risk for chronic diseases such as obesity, cardiovascular disease, cancer, and high blood pressure. Childhood abuse and neglect increase the likelihood of juvenile arrest, teen pregnancy, and adult criminal behavior.
On the PathologyPrevention website, when we review the management of the related health records concerning intimate Partner Violence including Physical violence, Sexual violence, Stalking, and Psychological aggression the term ‘physical violence’ will indicate the use of any force that could cause death, disability, injury, or trauma. By ‘sexual violence’ we include any attempted or completed sex acts without the consent of the other person. Acts of sexual violence include, but are not limited to, rape, unwanted sexual contact, and exposure to sexual situations (e.g., pornography). Stalking is defined as repeated, unwanted attention that leads to fear (e.g., repeated phone calls, spying, and damaging personal property). Psychological aggression is a form of emotional abuse wherein the aggressor uses verbal or nonverbal communication to exert control or harm the person emotionally.
In each of these types of Intimate Partner Violence, specific events may occur in an instant, or they can happen imperceptibly slowly over a lifetime. By recording events that you feel might be something to be concerned with you gain a better perspective over time and may need both subjective and objective data while discussing thoughts and feeling with your Health Guardian. The same will be true in the cases of Child Abuse and Neglect, or Elder Abuse and Neglect.
Documentation of Intimate Partner Violence, Child Abuse, and Elder Abuse must include detailed, nonbiased progress notes, injury maps, and photographic documentation as appropriate. Written documentation of histories needs to be verbatim but within reason. It may be unrealistic to transcribe everything that happens, or what a person tells you, but it is important to capture exceptionally poignant phrases. Phrases that identify the reported perpetrator and serve threats of harm made by the reported perpetrator are important. Other aspects of the abuse history, including reports of past abusive incidents, can be paraphrased with the use of partial direct quotations.
When quoting or paraphrasing the history, you should not sanitize your words. Verbatim documentation of the recorded perpetrator’s threats interlaced with curses and expletives might be useful in future court proceedings. Also be careful to use the exact terms that as an abused patient you use to describe sexual organs or sexually assaultive behaviors. The value of these health records increase, and become more affective in recognizing the truth and addressing the physical, mental, and spiritual trauma experienced.
Documentation of your physical examination (a self-examination or third-party) needs to be thorough and unbiased. Do not speculate on what caused the injury, or why you think something was done; instead, document what you observed and what you directly experienced. Digital photographic documentation in the medical record can be invaluable.