The following should be documented in the patient’s charts:
- Confirmation that the patient was screened for IPV or the reason the screening did not take place
- Patients response to screening
- Documentation of resources provided such as safety cards
- Any referrals provided
For more information on documentation, see page 18 of the National Consensus Guidelines. For evidence collection, see Appendix K in the Consensus Guidelines.
- National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health care Settings
This resource provides practical strategies for documentation such as the importance of using the patients’ own words to describe what happened and avoiding using judgmental states such as “patient refuses help”.