**Guidelines for Clinical Assessment and Intervention**

**Introduction:**

Physical and sexual violence against women is a public health problem of
epidemic proportions.

3-4 million women in the United States are battered by their former or
current partners annually. These numbers represent only those documented
cases. Incidence is likely much higher as many never seek assistance. It
is estimated that 30% of female murder victims in the United States are
killed by a current or former partner.

In addition to the physical and psychological issues related to domestic
violence, it has been shown that children raised in these situations are
at risk to continue this cycle of violence whether it is domestic or
non-domestic. Alcohol and drug use and dependence are also increased
among both the victims and the children involved in these situations.
Domestic violence occurs in every sector of society and among all races.
It occurs in both heterosexual and homosexual relationships. The US
Department of Justice estimates that 95% of reported assaults on spouses
or ex-spouses are committed by men against women.

The Warm Springs Community is not immune to domestic violence and it
plays a tremendous role in the health of this and any community,
therefore we must place identification and intervention of this issue in
the foremost part of our mind and take it as a very serious concern.

# Purpose:

Medical practitioners are often the first or the only professionals to
come into contact with individuals in abusive situations. We have a
unique responsibility and opportunity to intervene. Traditionally health
care practitioners are not instructed in such intervention or in how to
respond appropriately when domestic violence affects their patient's
life. The purpose of this protocol is to aid in identification,
treatment and intervention in such situations.

Since 1992 the Joint Commission Accreditation of Health Care
Organizations has required that all accredited hospitals implement
policies and procedures in the emergency and ambulatory care facilities
for identifying and treating and referring victims of domestic abuse.
These standards include educational programs for staff in domestic
violence. This protocol is intended to assist medical professionals in
complying with these standards and thus improving service to this group
of patients. Training for health care providers has proven to be very
effective in implementing and improving the quality of health care given
to battered patients. Our policies will include procedures for
identifying and documenting partner abuse, providing patient information
about community resources and educating staff on handling these cases.

As the great majority of victims are female, they will be referred to a
"she" for the purposes of this document. We do recognize that violence
occurs female to male and in same sex relationships. The same guidelines
apply in these cases.

# Guiding Principles:

1.  Treat patients with dignity, respect, and compassion and with
    sensitivity to age, culture, ethnicity and sexual orientation, while
    recognizing that domestic violence is unacceptable in any
    relationship.

2.  Recognize that the process of leaving a violent relationship is
    often a long and gradual one.

3.  Attempt to engage patients in long-term continuity of care within
    the health care system, in order to support them through the process
    of attaining greater safety and control in their lives.

4.  Regard the safety of victims and their children as priority.

## I. Screening. Domestic violence and its sequel are present in numbers to justify routine screening. Early recognition and intervention can significantly reduce the morbidity and mortality that results from violence in the home. A woman may not initially recognize herself as "battered"; therefore the medical professional should routinely ask all women direct specific questions about abuse. {#i.-screening.-domestic-violence-and-its-sequel-are-present-in-numbers-to-justify-routine-screening.-early-recognition-and-intervention-can-significantly-reduce-the-morbidity-and-mortality-that-results-from-violence-in-the-home.-a-woman-may-not-initially-recognize-herself-as-battered-therefore-the-medical-professional-should-routinely-ask-all-women-direct-specific-questions-about-abuse. .unnumbered}

> **A. Who to Screen.**

1.  All women and adolescent girls in a primary care or inpatient
    setting

2.  Men and adolescent boys who present with symptoms or signs of
    domestic violence.

3.  Pediatric visit- Screen all parents or legal guardians who present
    with signs or symptoms of domestic violence. (If there are children
    in the room at the time of screening remove them if possible.)

> 4\. Clinical Findings that may indicate abuse\...
>
> Alcohol or drug abuse Injury inconsistent with patients explanation
>
> Repeated use of the ER Eating disorders
>
> Chronic pain syndromes Injury during pregnancy
>
> Prior history of trauma vague psychosomatic complaints
>
> Multiple injuries in various stages of healing A partner who will not
> leave the exam room
>
> Injury to the head, neck, torso, genitals, breast or abdomen
>
> Delay between onset of injury and seeking care
>
> Psychological distress (suicidal, depression, anxiety or sleep
> disorders)

###  B. When to Screen

###  Screening should be done [every six months]{.underline} for all women and adolescent girls. 

### Physical exams, Pap and breast exams and contraceptive injection visit are ideal times for screening to

###  occur. 

Men and children should be screened as above on an as needed basis.

Screening should also occur on an as indicated basis per the suggestions
in section IA.4.

###  

###  C. How to Screen 

1.  Screen in a safe environment. Separate any accompanying persons from
    the patient when screening for domestic violence. Ask the patient
    about domestic violence in a private place. If this cannot be done
    postpone screening for a follow up visit.

2.  Use your own words in a non-threatening, non-judgmental way.
    *"Domestic Violence is so common I ask all my female patients about
    abuse in the home"*

> 3\. Use questions that are direct, specific and easy to understand.
> *Do you feel safe in your current relationship?*
>
> *Have you or your children ever been threatened or abused (physically,
> sexually or emotionally) by your partner?*
>
> *Is there a partner from a previous relationship who is making you
> feel unsafe?*

3.  Discuss with patients the confidentiality of these questions and the
    mandatory reporting of child abuse.

Remember that the patient may deny abuse if she is not ready to deal
with the situation or is in denial. Even if you are certain of an
abusive situation do not force the issue with her. The decision to leave
or take action needs to be hers.

##  {#section-1 .unnumbered}

##  {#section-2 .unnumbered}

##  {#section-3 .unnumbered}

##  {#section-4 .unnumbered}

##  {#section-5 .unnumbered}

##  {#section-6 .unnumbered}

##   {#section-7 .unnumbered}

## D. Document that screening for domestic violence was done. {#d.-document-that-screening-for-domestic-violence-was-done. .unnumbered}

For sites using the Resource and Patient Management System (RPMS) the
documentation should be recorded on the Patient Care Component (PCC)
form in the Purpose of Visit section as:

**HF -- DV** \[HF indicates Health Factor\]

The data entry staff should enter this using the **HF** mnemonic:

**HF -- DV SCREENING**

> Document as Personal History PHX Domestic Violence Screening negative
> 8/8/99
>
> For positive screens or acute instances of abuse, document in PCC
> Problem list.
>
> EX.

WSP 6 Adult abuse 995.80

WSP6.1 Emotional, physical, sexual

WSP 6.2 hospitalized 4/98 fractured jaw

WSP 6.2 Victims Assistance referral 5/2/98

## Assessment 

##  Negative Screening 

-   Document that screening was done.

-   Document any educational efforts.

-   Document any concerns.

-   Screening at a regular interval

**B. Positive Screening**

> 1\. Be supportive of the patient with statements such as...

-   *No one deserves to be abused.*

-   *There is no excuse for domestic violence.*

-   *The violence is not your fault; this is the responsibility of the
    abuser.*

#### You are not alone; there are people you can talk to for support.

-   *It must be very difficult for you to leave your situation. We are
    here to help when you are ready.*

2.  Explain to the patient that documentation of past and future
    incidents with a medical facility or with the police may be
    beneficial to her in the event she takes legal action in the future.

3.  Assess any immediate danger for the patient before she leaves the
    office. Indicators of escalating danger:

-   An increase in frequency or severity of the assaults

-   Increasing of new threats of homicide or suicide

-   Threats to children

-   A firearm or deadly weapon in the home

4.  Give the patient resource information phone numbers and safety plan
    information. (Appendix 3)

#######  EX. 

####### Warm Springs Victims \' Assistance 553-2293

> COBRA 24-hour hotline 1-800-356-2369

Madras Office 475-1880

WSH&WS Social Services ext. 4498

> 5\. If time is limited, help her set up a future appointment with a
> provider she chooses to discuss and document
>
> these issues.
>
> **C. Acute Incident.** History and physical exam should be recorded on
> the ["Domestic Violence Assessment and]{.underline}
>
> [Intervention"]{.underline} form, Appendix 1.
>
> 1\. Explain to the patient your concerns and the importance of
> documentation of present and past injuries for her benefit in event of
> future legal proceedings; obtain verbal agreement of exam. A written
> consent should be obtained for photographs.

2.  History of Present Complaint

-   Use the patient's exact words and descriptions of events when ever
    possible.

-   Record "excited utterances" and use descriptive terms in regards to
    emotions and

> appearance.

3.  Record significant or relevant past history and medical problems.

-   Include hospitalizations and, surgery, resulting from violence.

-   Have the police been called in the past?

-   Has she had to seek safe shelter?

3.  

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4.  During the physical exam, examine any scars (old and new) with
    documentation of the patient's explanation of each. (Kicked by a
    boot, hit with a bottle etc.) Document scars, wounds, and bruises on
    anatomic drawing and with photographs.

5\. Be supportive of the patient. Good statements to use are:

-   *No one deserves to be abused*

-   *There is no excuse for domestic violence*

-   *The violence is not your fault; this is the choice of the abuser.*

-   *You are not alone; there are people you can talk to for support*

-   *It must be very difficult for you to leave your situation. We are
    here to help you when you*

> *are ready*
>
> 6\. Before the patient leaves address the following issues
>
> **Immediate** **Risk:** *If you return to your home will you be in
> immediate physical danger?*
>
> *Do you have a safe place to go*?
>
> **State of mind toward situation and possible change***:*

-   *What type of assistance would you like?*

-   *Are there any changes you would like to make in your life?*

-   *What steps or action are you ready to make toward those goal*?

-   *Are you* *having any suicidal thoughts?*

> **D. Expanded Assessment.** This may need to continue in follow up
> visits

1.  Assessment of the patients general view toward personal situation

-   How has the abuse affected you?

-   What do you do to cope with the abuse?

-   What would you like to see happen for yourself and your children?

2.  Degree of abusers control over patient

-   *Does your partner ever try to control you through threats to you,
    your family or pets?*

-   *Does your partner try to restrict your freedom to see friends or
    family/?*

-   *Do you have your own money or financial support?*

-   *Do you feel like you are walking on eggshells around your partner?*

-   *Do you feel like you are controlled or isolated by your partner?*

3.  Effects on Health: What types of medical and psychological effects
    have resulted from abuse.

-   Alcohol or drug abuse

-   Eating disorders

-   Chronic pain syndromes

-   Psychological distress (suicidal, depression, anxiety or sleep
    disorders)

-   Psycho-somatic syndromes

### 

4.  Effects of abuse on children:

-   Have your children shown any signs of physical injuries, sexual
    abuse that could be related to your partner's abuse. (Eating
    disorders, bad dreams, somatic complaints, school problems,
    depression, suicidal thoughts, behavior problems)

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-   Have they witnessed the abuse?

5.  Further assessment of suicide/homicide

-   Have you ever-attempted suicide in the past?

-   Are you having thoughts of suicide now? Do you have a plan?

-   Have you thought about harming or killing your partner?

## Intervention

A.  **Treat any medical injuries.**

> If hospitalization is necessary for protection or medical
> interventions use "Adult Maltreatment Syndrome"
>
> ICD-9-CM 995.81

B.  **Reiterate the following messages:**

-   *No one deserves to be abused*

-   *There is no excuse for domestic violence*

-   *The violence is not you fault only the abuser is responsible*

-   *You are not alone; there are people you can talk to for support.*

-   *It must be very difficult for you to leave you situation. We are
    here to help you when you*

> *are ready*

**Do not tell the woman she must leave.** The decision to leave needs to
be her own. Leaving can be the most dangerous time for the woman. Most
women killed in these situations are killed when they are attempting to
leave or have tried to terminate the relationship. There needs to be a
carefully thought out safety plan in place.

**C. Provide Educational Information about Domestic Violence.** Include
the following:

-   *Domestic violence occurs often in our society and affects all
    races, religions, classes and ethnic groups.*

-   *Over time most violence increases in severity and frequency and
    continues.*

-   *Violence in the home can leave long term, damaging effects on
    children, particularly physically when hurt or witness the abuse.*

-   *Domestic violence is a crime in the U.S.*

-   *There are social and legal service options, which include shelters,
    restraining orders, police assistance, and counseling*.

D.  **Assist the patient in making a safety plan.**

-   What do you want to do now? Long term?

-   Do you have a place to go where you will be safe? Do you want to go
    to a shelter?

-   Do you want a restraining order? (Victims assistance can aid in
    obtaining)

-   Do you want to set up a safety plan? (See appendix 3)

**E. Give the patient resource information**. Contact Victims'
Assistance, Clinic social worker, or COBRA. If the

patient desires.

#######  Warm Springs Victims\' Assistance 553-2293

> COBRA 24-hour hotline 1-800-356-2369

Madras Office 475-1880

WSH&WS Social Services ext. 4498

> **F. Police Intervention**

-   Inform the victim that in the event she elects to take legal action
    in the future, a police report on record may help her case. If the
    patient wishes to make a report to the police assist her in
    contacting the Warm Springs PD at 553-1171.

-   Stay in the room with the patient during the police interview.

-   Record the officer's name and badge number and document that a
    police report was made.

-   A copy of the medical report should be given to the officer.

**In the event injuries involve a knife or firearm legal authorities
must be notified regardless of victim authorization.**

##  IV Documentation Remember this may be your patients best evidence in event of a legal case. Detail and Accuracy are very important.  {#iv-documentation-remember-this-may-be-your-patients-best-evidence-in-event-of-a-legal-case.-detail-and-accuracy-are-very-important. .unnumbered}

## Use the [Domestic Violence Assessment and Intervention form]{.underline} ([Appendix]{.underline} 1.) as discussed in section II and III. 

-   Document with the Domestic Violence Screening Blue Chip that
    screening was done and **yes, no** or **unsure**

-   For positive screens or acute instances of abuse document in the
    health summary.

> WSP 6 Adult abuse 995.80

WSP6.1 Emotional, physical, sexual

WSP 6.2 hospitalized 4/98 fractured jaw

WSP 6.2 Victims Assistance referral 5/2/98

## V. Continuity of Care {#v.-continuity-of-care .unnumbered}

-   At each visit ask patients about history of violence since last
    visit, coping strategies, and counseling.

-   Has she called a hotline, attempted to leave or told family or
    friends about the situation.

-   Reiterate messages of support and concern.

-   Ask about the children.

## VI. Training. Mandatory training annually for [all staff]{.underline} regarding... {#vi.-training.-mandatory-training-annually-for-all-staff-regarding .unnumbered}

-   Domestic violence, the basics

-   Helping others in this situation

-   Resources

-   Legal issues

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Medical Social Worker Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Director: Date:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Service Unit Director Date:

##### 

**Appendix 1: Domestic Violence Assessment and Intervention**

**Patients
name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Chart #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Today's Date\_\_\_\_\_\_\_\_time\_\_\_\_\_\_\_ Date of
Assault\_\_\_\_\_\_\_\_\_\_time\_\_\_\_\_\_

Alleged assailants
name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Relationship to patient\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### 

####### History of Acute Events (Use the patients own words whenever possible, be detailed)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Names and Ages of any children** present in the home at the time of
assault

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Related Past History** (include violence in this relationship) Record
relevant ER or clinic visits, hospitalizations and the injuries
involved. Record related medical issues (chronic pain syndromes, suicide
attempts, alcohol, drug abuse etc.)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### Assess Patient Safety and Needs

Yes\_\_ No\_\_ Is the assailant still in the home?

Yes\_\_ No\_\_ Is the patient afraid to go home?

Yes\_\_ No\_\_ Have there been threats of suicide/homicide?

Yes\_\_ No\_\_ Has the abuse increase infrequency /intensity?

Yes\_\_ No\_\_ Is there a weapon in the home?

Yes\_\_ No\_\_ Does the patient want a restraining order?

Yes\_\_ No\_\_ Are alcohol or drugs involved?

Yes\_\_ No\_\_ Needs immediate shelter?

Yes\_\_ No\_\_ Victims Assistance/COBRA called?

Yes\_\_ No\_\_ Is there a safe \# where the patient can be reached?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Yes\_\_ No\_\_ Police Report made If yes...

> At scene or at clinic\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Police officers
> name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ badge
> #\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Yes\_\_ No\_\_ Copy of medical report given to officer

Yes\_\_ No\_\_ Photographed

Yes\_\_ No\_\_ Info packet given?

Yes\_\_ No\_\_ Follow up appointment made been made?
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Yes\_\_ No\_\_ Referrals made?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Yes\_\_ No\_\_ Has "Adult Abuse " been documented in health summary?

*Over for physical exam*

####### 

####### Physical Exam Note: If sexual assault is included use Appendix 2 [Sexual Assault History and Physical]{.underline} form also.

Describe all injuries, location, size, and cause per the patient's
report. I.e. kicked with boot, thrown into wall.

With patients written consent, photograph her, include at least one face
photo for identification, and photograph all wounds. For bruises
lacerations etc. place a ruler in the photo for a size comparison.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

![](media/image1.bmp)

  ----------- ----------- ---------- ------------ ---------- ---------- ---------- ---------
  Area        Contusion   Abrasion   Laceration   Bleeding   Fracture   Lost       Painful
                                                                        function   areas

  Head                                                                             

  Ears                                                                             

  Cheeks                                                                           

  Mouth                                                                            

  Neck                                                                             

  Shoulders                                                                        

  Arms                                                                             

  Hands                                                                            

  Chest                                                                            

  Back                                                                             

  Abdomen                                                                          

  Genitals                                                                         

  Buttocks                                                                         

  Legs                                                                             

  Feet                                                                             
  ----------- ----------- ---------- ------------ ---------- ---------- ---------- ---------

Provider
Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Appendix 2: Sexual Assault History and Physical Exam**

**Patients Name**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sex M\_\_ F\_\_

Date of Birth \_\_\_/\_\_\_/\_\_\_

Date of Sexual Assault \_\_\_/\_\_\_/\_\_\_ Time of Sexual Assault
\_\_\_:\_\_\_\_ AM/PM

1.  Where did the assault take
    place\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  Physically Injured How?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  Number of Assailants\_\_\_\_\_\_\_\_\_

4.  Yes\_\_ No\_\_ Was there loss of consciousness at any time?

5.  Yes\_\_ No\_\_ Any kind of weapons involved?
    Type\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  Yes\_\_ No\_\_ Were restraints used?
    Type\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  Yes\_\_ No\_\_ Did the assailant place or attempt to place his penis
    in your:

\_\_Vagina \_\_Mouth \_\_Anus

8.  Yes\_\_ No\_\_ Did the assailant insert any foreign object into your
    vagina, mouth or rectum?

> Specify object
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9\. Yes\_\_ No\_\_ Not Sure\_\_ Did the assailant ejaculate? What part
of body? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10\. Yes\_\_ No\_\_ Not sure\_\_ Use a condom?

11\. Yes\_\_\_ No\_\_ Did you scratch the assailant?

12. Yes\_\_ No\_\_ Have you consumed any drugs or alcohol before during
    or after the assault either

> voluntarily or by force?

  ----------- ----------- ----------- ----------- ----------- -----------
              Before      During      After       Forced      Voluntary

  Alcohol                                                     

  Drugs                                                       
  ----------- ----------- ----------- ----------- ----------- -----------

13\. Since the assault, have you:

\_\_Douched \_\_ Defecated \_\_Bathed \_\_ Changed Clothes

\_\_Gargled \_\_ Eaten \_\_Urinated \_\_ Drunk

# Gynecological History

1.  Date of Last menstrual period \_\_/\_\_\_/\_\_\_

2.  Did you have a tampon in place at the time of assault? Yes\_\_\_
    No\_\_\_

3.  Are you pregnant? Yes\_\_\_ No\_\_\_ Unsure\_\_\_ Due date
    \_\_/\_\_/\_\_

4.  Were you using any contraceptive at the time of assault? Yes\_\_\_
    No\_\_\_

5.  Any recent gynecological
    problems\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  Date and time of last
    intercourse\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######## Physical Exam If a "Rape Kit" is not available collect the following specimens for evidence.

\_\_\_Vaginal smear (air dry)

\_\_\_Cervical smear (air dry)

\_\_\_Wet mount of vaginal/cervical swab for sperm presence

\_\_\_Vaginal aspirate for acid phosphatase test (with 5cc normal saline
and sterile syringe)

\_\_\_Seminal Swab (moistened swab to area indicated per ejaculation
history)

\_\_\_Nail scrapings

\_\_\_Pubic hair combing

\_\_\_ Garments worn during incident

\_\_\_ Culture for GC, Chlamydia (may opt to treat prophylacticaly, not
for evidence)

  ----------- ----------- ---------- ------------ ---------- ---------- ---------- --------
  Area        Contusion   Abrasion   Laceration   Bleeding   Fracture   Lost       Pain
                                                                        Function   

  Head                                                                             

  Ears                                                                             

  Cheeks                                                                           

  Mouth                                                                            

  Neck                                                                             

  Shoulders                                                                        

  Arms                                                                             

  Hands                                                                            

  Chest                                                                            

  Back                                                                             

  Abdomen                                                                          

  Buttocks                                                                         

  Legs                                                                             

  Feet                                                                             

  Perineum                                                                         

  Vag vault                                                                        

  Perianal                                                                         

  Penis                                                                            

  Rectal                                                                           
  ----------- ----------- ---------- ------------ ---------- ---------- ---------- --------

![](media/image2.bmp)

**Treatment**

Yes \_\_ No\_\_ Emergency Contraception offered?

Yes \_\_ No\_\_ STD prophylaxis offered? (Suprax, Azithromycin)

Yes \_\_ No\_\_ HIV testing offered?

Yes \_\_ No\_\_ Pregnancy testing done?

Yes \_\_ No\_\_ Referral to Victims Assistance/COBRA?

Yes \_\_ No\_\_ Police Report made? Officer's
name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Badge #\_\_\_\_\_\_\_\_\_\_

**Physician/Nurse Practitioner Signature**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_ Time \_\_\_\_\_\_\_\_\_\_

**Appendix 3 Domestic Violence Safety Plan**

> Safety Planning

If you are living with a person who is abusing or battering you, here
are some things you can do to ensure the safety of you and your
children.

> Call 911 in event immediate danger!

**"Flight Kit"** This should be kept packed and hidden in a safe place,
possibly at the home of a trusted friend or relative.

-   Clothes for her and children

-   Money

-   Extra car keys

-   Important records (birth certificates, custody papers, insurance
    card, food stamps, social security cards, marriage licenses etc.)

-   Keep change for a pay phone with you at all times

###### 

###### Crisis lines memorize these numbers or write them in a secure place

-   Warm Springs Victims Assistance **553-2293**

-   COBRA (Central Oregon Battery and Rape Alliance) **475-1880**

**1-800-356-2369 (24-hour hotline)**

**Teach children the use of 911** and develop a code with your children
or a friend to call for help.

Ex: " Have you worked on your science project? Means go to the
neighbor's house and call the police.

**Plan for a place to go** in event of an emergency. Some suggestions
are the home of a relative or friend, a women's shelter \[numbers
above\] or hospital. Stay in touch with friends and get to know your
neighbors.

**Medical Records:** If you are seen in a clinic or hospital for your
injuries related to domestic violence ask the medical staff to do
detailed documentation and to take photographs. You can obtain copies of
these records if needed. These may be beneficial to you in future legal
proceedings (assault, divorce, and custody).

**Money:** If at all possible open a secret bank account so that you
will have money when you are ready to leave.

Many women do not identify themselves as battered. They may think their
situation is normal and that all men beat their partners. Family members
may tell them that violence is a part of the marriage vows. The woman
may be made to believe that she is an unfit wife by her partner, even
her family, and that she is deserving of abuse.

All couples argue and fight at one time or another. We all say mean
things that hurt each other at times. When these things are done to gain
control over the partner, it is abuse.

**Abuse is intended to force the victim to do something the abuser
wants, without any**

**concern for her rights as a human being.**

> ![](media/image3.wmf)**Physical abuse**: This includes acts in which
> physical force is used to coerce the victim. This might include
> pushing, shoving, or being held against her will; slapped, kicked,
> bit, choked or punched. He may throw objects, locked her out or the
> house, abandon her in a dangerous place or force her into a dangerous
> situation. There may be threats or use of weapons and rape
>
> ![](media/image4.wmf)**Sexual Abuse**: Sexual abuse is most often
> thought of as rape or forced sexual actions. It can also include
> forced undressing or watching of sexual acts. Forced sex when in
> danger, sick or after a beating are also forms of sexual abuse. Sexual
> abuse might also include anti-woman or demeaning jokes or name-calling
> (frigid, whore) intended to degrade the victim. A woman might be
> treated as a sexual object and be made to dress in a sexual manner
> with which she is not comfortable. There may be jealous accusations
> regarding sex or the abuser may minimize his partner's feelings about
> sex.
>
> ![](media/image5.jpeg)**Emotional/ Mental Abuse**: In emotional or
> mental abuse the victim's feelings may be ignored and minimized while
> excessive attention is demanded to the abusers needs. He may ridicule
> the victim or women as a group with the intent to degrade her. He may
> also ridicule her beliefs, values, religion, class, heritage or race.
> As punishment there may be withholding of approval or name calling. He
> may isolate her by driving away friends and /or family. She may be
> kept from working or be forced to work. He may demand complete control
> of money and refuse to share the workload. He may threaten to take the
> children or abuse her pets. Manipulation with lies and contradictions
> is abusive behavior, as are threats of violence, suicide, and
> homicide.