**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.

**Definition:**

Domestic Violence is a pattern of assaultive and coercive behaviors,
including physical, sexual and psychological attacks, as well as
economic coercion that adults and adolescents use in effort to control
their intimate partners.

# 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 it's 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.  Children - Screen female caregiver/parents or caregivers known to be
    in a same sex relationship who accompany their children

> 4\. Any patients who present with 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

### Women and adolescent girls- screening will be done for all presenting for examination... 

###  At new patient visits

###  Every six months 

###  At disclosure of a new intimate relationship. 

1.  Screening in pregnancy will occur...

> At the first prenatal visit
>
> At first prenatal visit and at least once during each trimester of
> pregnancy during prenatal
>
> care
>
> During post- partum visits

2.  Pediatric visit - Female caregiver/parents who accompany their
    children will be screened...

> During new pediatric patient visits
>
> At each well child visit during the first year of life and then once
> per year at well child visits
>
> At disclosure of a new intimate relationship

3.  Pediatric visit-female or male caregiver/parents known to be in same
    sex relationships who accompany their children will be screened...

> During new pediatric patient visits
>
> At each well child visit during the first year of life and then once
> per year at well child visits
>
> At disclosure of a new intimate relationship

4.  Men will be screened on an as indicated basis.

5.  Screening will 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?*

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

5.  The" WSH&WC Screening Questionnaire" may be used when children older
    than 2 years old are in the room or in the treatment room were
    privacy may be of concern.

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-2 .unnumbered}

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

> Document under the education section of PCC+ form circling the
> appropriate response
>
> **DV P (**positive)**, N** (negative) or **S** (suspect)
>
> Document as Personal History Phx Domestic Violence Screening negative
> 8/8/99
>
> For positive screens or acute instances of abuse, document in the
> health summary.
>
> EX.

WSP 6 Adult abuse 995.80

WSP6.1 Emotional, physical, sexual

WSP 6.2 hospitalized 4/98 fractured jaw

WSP 6.3 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\. Lethality Assessment- 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

-   Will you be safe if you return home?

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

#######  

####### 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 choose or with the clinic

> social worker to discuss and document these issues.

A.  **Acute Incident.** History and physical exam should be recorded on
    the ["Domestic Violence]{.underline}

> [Assessment and 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.  

```{=html}
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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.  Lethality Assessment- 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

-   Will you be safe if you return home?

> 6\. Immediate Risk**:** *If you return to your home will you be in
> immediate physical danger?*
>
> *Do you have a safe place to go*?

7\. 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?*

> 8\. 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*
>
> **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 patient's 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 1.) as discussed in section II and III. 

-   Document with the under education section DV P-positive, N- negative
    , S- Suspicious

-   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 ak 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 and during orientation for [all staff]{.underline} regarding... {#vi.-training.-mandatory-training-annually-and-during-orientation-for-all-staff-regarding .unnumbered}

-   Domestic violence, the basics

-   Helping others in this situation

-   Resources

-   Legal issues

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

**Patient's
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 follow [Sexual Assault Protocols: Warm Springs Health and Wellness Center]{.underline}. Describe all injuries, location, size, and cause per the patient's report. I.e." kicked with boot, thrown into wall". With patient's 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 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_