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.