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.
In 2011 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” (ASPE, 2013).
In January 2013 the U.S. Preventive Services Task Force (USPSTF) changed its recommendations regarding screening for IPV in women of childbearing age, and screening for abuse and neglect in elders. The task force
recommends that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services.
The task force also
concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect. (USPSTF, 2013)
Prior to January 2013 the recommendation regarding IPV had been similar to the current one for abuse and neglect of elders. The research and reasoning that goes into recommendations as well as suggestions for implementation of recommendations are discussed in detail on the USPFSTF website.
In discussing specific tools for screening, the task force notes that several instruments can be used to screen women for IPV. Those with the highest levels of sensitivity and specificity for identifying IPV are:
- Hurt, Insult, Threaten, Scream (HITS)—includes four questions, can be used in a primary care setting, and is available in both English and Spanish. It can be self- or clinician-administered.
- Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT)
- Slapped, Threatened, and Throw (STaT)—three-item self-report instrument that was tested in an emergency department setting
- Humiliation, Afraid, Rape, Kick (HARK)—self-administered four-item instrument
- Modified Childhood Trauma Questionnaire—Short Form (CTQ-SF)
- Woman Abuse Screen Tool (WAST)
The task force found no valid reliable screening tools to identify abuse of elderly or vulnerable adults in the primary care setting. However, the accompanying discussion reveals that this may be more about a lack of data, many variables, and the need for more research and practice (USPSTF, 2013).
The CDC has supported at least two studies to evaluate assessment tools, and their reports can be consulted via the CDC website by anyone looking for more information about available screening tools for varying practice settings. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version 1 was published in 2007, and Measuring Intimate Partner Violence Victimization and Perpetration: A Compendium of Assessment Tools in 2006.
Healthcare professionals should make sure they understand and are trained to use any procedures, tools, and forms their institution already has in place for screening and assessment. In addition, it is important to be up-to-date on your state’s requirements for reporting and documenting domestic violence information.
Medical records are often used as evidence in domestic violence cases. 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. For example, “excited utterances” or “spontaneous exclamations” should be carefully documented because they have exceptional credibility due to their proximity to the event and because they are not likely to be premeditated. The victim or the victim’s attorney can use a medical record to obtain a restraining order, qualify for special status or exemptions in public housing, welfare, health and life insurance, victim compensation, and immigration relief related to domestic violence and in resolving landlord-tenant disputes (Isaac & Enos, 2001).
According to a number of studies, many medical records are not sufficiently well-documented to provide adequate legal evidence of domestic violence. A study of 184 visits for medical care in which an injury or other evidence of abuse was noted revealed major shortcomings in the records:
- For the 93 instances of an injury, the records contained only 1 photograph. There was no mention in any records of photographs filed elsewhere (for example, with the police).
- A body map documenting the injury was included in only 3 of the 93 instances. Drawings of the injuries appeared in 8 of the 93 instances.
- Doctors’ and nurses’ handwriting was illegible in key portions of the records in one-third of the patients’ visits in which abuse or injury was noted.
- Criteria for considering a patient’s words an “excited utterance” were met in only 28 of the more than 800 statements evaluated (3.4%). Most frequently missing was a description of the patient’s demeanor, and often the patient was not clearly identified as the source of the information. (Isaac & Enos, 2001)
Medical records could be more useful to domestic violence victims in legal proceedings if some minor changes were made in documentation. Clinicians can do the following:
- Take photographs of injuries known or suspected to have resulted from domestic violence.
- Write legibly. Computers can also help overcome the common problem of illegible handwriting.
- Set off the patient’s own words in quotation marks or use such phrases as “patient states” or “patient reports” to indicate that the information recorded reflects the patient’s words. To write “patient was kicked in abdomen” obscures the identity of the speaker.
- Avoid such phrases as “patient claims” or “patient alleges,” which imply doubt about the patient’s reliability. If the clinician’s observations conflict with the patient’s statements, the clinician should record the reason for the difference.
- Describe the person who hurt the patient by using quotation marks to set off the statement. The clinician would write, for example: The patient stated, “My boyfriend kicked and punched me.”
- Avoid summarizing a patient’s report of abuse in conclusive terms. If such language as “patient is a battered woman,” “assault and battery,” or “rape” lacks sufficient accompanying factual information, it is not admissible.
- Do not place the term domestic violence or abbreviations such as “DV” or “IPV” in the diagnosis section of the medical record. Such terms do not convey factual information and are not medical terminology. Whether domestic violence has occurred is determined by the court.
- Describe the patient’s demeanor—indicating, for example, whether she is crying or shaking or seems angry, agitated, upset, calm, or happy. Even if the patient’s demeanor belies the evidence of abuse, the clinician’s observations of that demeanor should be recorded.
- Record the time of day the patient is examined and, if possible, indicate how much time has elapsed since the abuse occurred. For example, the clinician might write, “Patient states that early this morning his boyfriend hit him” (Isaac & Enos, 2001).