There is a reluctance by both women and men to report intimate partner violence. Most people who were physically assaulted do not file a complaint, although women were more likely than men to report their victimization to the police.
Many healthcare and social services professionals are already involved with screening and assessment of clients for domestic violence, including intimate partner violence. Numerous professional associations have taken positions advocating screening of most, if not all, adults. As with all aspects of domestic violence, there are gaps in the research and thus sometimes contradictory findings and positions, and more research is needed.
Over 80% of victims of domestic and family violence seek care in a hospital. Others may seek care in health professional offices, including dentists, therapists, and other settings. Routine screening should be conducted by all healthcare practitioners including nurses, physicians, physician assistants, dentists, nurse practitioners, and pharmacists. Screening is a critical component protecting victims and minimizing negative health outcomes (Houseman and Semien, 2022).
3.1 Screening Tools
More than a decade ago, the Institute of Medicine (IOM) released a report on preventive services with recommendations that were quickly adopted by the U.S. Department of Health and Human Services. One of the recommendations was to provide screening and counseling to women regarding “interpersonal and domestic violence.”
In 2018 the U.S. Preventive Services Task Force (USPSTF) provided recommendations regarding screening for intimate partner violence in women of reproductive age, and screening for abuse and neglect in elders. The task force recommended that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services.
Clinicians should also screen for child abuse, child neglect, and elder abuse and neglect. All clinicians should be aware of the potential signs and symptoms of child and elder abuse and should be familiar with screening tools. When elder abuse is suspected, the history and physical exam should be carefully conducted and documented with additional laboratory, and imaging tests considered (Houseman and Semien, 2022).
In discussing specific tools for screening, the task force notes that several instruments can be used to screen women for intimate partner violence. Those with the highest levels of sensitivity and specificity for identifying IPV are (USPSTF, 2018):
- Hurt, Insult, Threaten, Scream (HITS)—includes 4 items that assess the frequency of IPV.
- Partner Violence Screen (PVS)—includes 3 items that assess physical abuse and safety.
- Humiliation, Afraid, Rape, Kick (HARK)—includes four questions that assess emotional and physical IPV in the past year.
- Woman Abuse Screen Tool (WAST)—includes 8 items that assess physical and emotional IPV.
- Additional screening tools recommended in CDC’s Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings include:
- Routinely, Ask, Document, Assess, Review (RADAR)—helps providers recognize and treat intimate partner violence.
- Abuse, Assessment, Screen (AAS)—A tool used to detect abuse limited to women.
Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities (Huecker et al., 2023).
If there is no immediate danger, the assessment should focus on mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention (Huecker et al., 2023).
During the initial assessment, a practitioner must be sensitive to the patient’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of being victims of domestic violence may allow more effective treatment (Huecker et al., 2023).
Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being. They may be weighing the tradeoff associated with leaving the abuser, leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary, and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, and enhance support (Huecker et al., 2023).
If the patient elects to leave their current situation, information for referral to a local domestic violence shelter to assist the victim should be given. If there is a risk to life or limb, or evidence of injury, the patient should be referred to local law enforcement officials. Counselors often include social workers, psychiatrists, and psychologists that specialize in the care of battered partners and children (Huecker et al., 2023).
Clear, concise, and factual documentation can help establish that abuse has occurred. Medical professionals may not be aware that subtle differences in the way they document cases of domestic abuse can affect the usefulness of their records if there is a hearing. Many medical records are not sufficiently well-documented to provide adequate legal evidence of domestic violence.
The medical record is often the most important evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again. Charting should include detailed documentation of evaluation, treatment, and referrals (Huecker et al., 2023).
- Describe the abusive event and current complaints using the patient's own words.
- Include the behavior of the patient in the record.
- Include health problems related to the abuse.
- Include the alleged perpetrator's name, relationship, and address.
The physical exam should include a description of the patient's injuries including location, color, size, amount, and degree of age bruises and contusions. Additionally (Huecker et al., 2023):
- Document injuries with anatomical diagrams and photographs.
- Include the name of the patient, medical record number, date, and time of the photograph, and witnesses on the back of each photograph.
- Photograph torn and damaged clothing.
- Document injuries not shown clearly by photographs with line drawings.
- Follow protocols for physical examination and evidence collection for sexual assault.
Minor improvements in documentation can be critical in a legal proceeding. As with all documentation, reporting should accurately describe the patient’s demeanor. Legible, clear writing without abbreviations, photographs of injuries, and the patient’s words in quotation marks reflect the patient’s own words. Avoid descriptions such as “battered woman” that may not be legally admissible—especially if the medical record fails to include supporting evidence. In the patient’s own words, include the time and date that the abuse occurred.