The clearer, more detailed and more thorough your documentation, the less likely you will be further involved if there is a legal case. Good records will also greatly assist your patient in a successful outcome of her case.
"If I have your records and good documentation, why would I risk bringing you to court?...I will simply introduce them into evidence rather than give the defense attorney an opportunity to cross-examine you. --- Cindy Dyer, Asst. DA, Dallas, TX
[From Salber & Taliaferro in Resources]
If you do go to court, you must be able to testify that:
- the records were made during the "regular course of business"
- the records were made in accordance with routinely followed procedures
- the records have been properly stored, and their access limited to professional staff
Documenting history of abuse (no injury)
- Write legibly
- Use neutral language – write patient “states” rather than “alleges”
- Use the patient’s own words in quotes
- Describe the situation in detail – who, what, when, where, how (threats? weapons or objects used? witnesses?)
- Describe other incidents/pattern of abuse, threats
- Describe physical and mental health consequences
- Do not include extraneous comments patient makes
- Document assessments (psych, safety, child/elder abuse)
- Giving a psych diagnosis may be used in court against patient in a custody battle – be sure and include relationship of abuse to psych symptoms, and the efforts patient has made to protect and care for self and children
- Document any referrals (social services, hotlines, mental health, legal aid, police)
- Document materials discussed, such as safety plan
- Establish safe way to contact patient
- Make follow up appt.
If injury, add
- What forms were filled out to document injuries
- What labs/xrays were ordered
- Where report was called in/filed
- Name of investigating officer and actions taken
At SUMC, contact Social Services (723-5091) when you identify an abused patient. Social Worker can assess and document many of these issues for you.
As a community physician/healthcare worker, call and ask trained hotline personnel to talk to the patient and help you with these assessments.