Documenting

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