# Presentation: 225922

## Domestic Violence

**Screening**
**Assessment**
**Intervention**
**Documentation**

- DONALD CLARK MD MPH ALBUQUERQUE IHS

**Notes:**
This online training module will deal with the clinical skills necessary to screen and assess patients for domestic violence, to formulate an appropriate intervention and review the elements of medical documentation. This curriculum is based on that developed by the Family Violence Prevention Fund. 

## Domestic Violence Is A:

***Pattern***** of assaultive and coercive behaviors, **
**Physical, sexual, and psychological and economic**
**That *****adults or adolescents***** use against their intimate partners or former partners.**** **

**Notes:**
This module deals with Intimate Partner Violence, not child abuse or elder abuse.
This is the definition taught by the Fund. 
A credible threat of physical or sexual violence is usually necessary to enforce the other forms of abuse.

## Domestic Violence:

- Chronic “disease”
- with acute exacerbations

**Notes:**
The victim of domestic violence is not responsible for starting or stopping the abuse, and in this sense is not “diseased”. But domestic violence can be compared to a chronic disease like diabetes or alcoholism, with variable periods of relative calm punctuated by more serious episodes of violence. Many providers are under the impression that domestic violence is only a problem at these times. Screening for domestic violence in the primary care setting is not only appropriate, but may provide a less stressful time and place for the patient to disclose this important aspect of her health. These visits may also offer more opportunities than visits for acute injuries to talk with patient without the abuser waiting. 
Whether we recognize DV or not, we see victims every day in all varieties of health care presentations and settings.

## Injuries

- Head and neck
- “Swimsuit” distribution
- Multiple sites
- Different stages of healing
- Inconsistent w/ mechanism of injury
- Delayed care

**Notes:**
We are used to thinking of DV in terms of physical injuries. It is true that not all women with these patterns of injury are victims of abuse. But it is equally true that we will not recognize many victims if we screen only those women who present with these patterns of injuries. 
Injuries to the head and neck are common, as are those in areas usually covered by clothing. Injuries in different sites in different stages of healing are very suggestive, just as they are for child abuse when noted on a child. Also similar to child abuse – injuries where the reported history just doesn’t make sense, or when care is delayed beyond the time a reasonable person would have waited.

## Medical Presentations

- Higher levels of smoking
- Chronic pain syndromes (GI, joint, chest, back, abdomen and pelvis)
- “Noncompliant”
- “Uncontrolled ____ “(fill in blank)

**Notes:**
Again a reminder that not every woman with these conditions is a victim of domestic violence, and many victims will not be identified if we screen only women with these presentations. These are patients whom we may question more carefully, or screen more frequently. 
Think of noncompliance as a symptom, not a disease. Many women may not be allowed to comply with your treatment recommendations because of the perpetrator’s demands. E.g. a diabetic may not comply with her exercise regimen because she cannot leave the house. A depressed patient repeatedly “loses” her SSRI and does not keep appointments in behavioral health because the perpetrator does not allow her to come to the hospital.
In addition, a compliant patient’s illness may become uncontrolled  due to increasing domestic violence. For example, we must consider infection as a possible cause of out of control blood sugars, but we should not forget to consider DV, too.

## Psychiatric Presentations

- Less favorable impression of physical and mental health status
- Nonconsensual sex
- Depression

**Notes:**
All of these conditions are more likely to occur in victims of domestic violence.

## Psychiatric Presentations

- Generalized anxiety
- Substance abuse
- PTSD

**Notes:**
All of these conditions are more likely to occur in victims of domestic violence.

## GYN Manifestations

- Sexual dysfunction
- Dyspareunia
- Recurrent UTI’s
- STD’s
- Chronic pelvic pain

**Notes:**
Pressure to have sexual intercourse, with or without threats of violence or rape. 
Abusers may place victims at risk by refusing to use condoms.

## OB Manifestations

- Late and intermittent prenatal care
- SAB and low birth weight babies
- Placental separation
- Antepartum hemorrhage
- Fetal fracture
- Preterm labor

**Notes:**
Homicide is the most common cause of death in women who are pregnant and during the postpartum period. It is more common than other causes of prenatal M&M. Not all these homicides are a result of DV. But by one estimate half of these deaths are due to DV.

## More abuse = more symptoms

- Medical Presentations

**Notes:**
The worse the abuse, the more symptoms and the more severe the symptoms. This has been shown to be the case for women with any or all of the presentations shown.

## Female homicides in NM:

- 4.9 per 100,000 Native American women
- 1.8 non-Hispanic white women
- 1.7 for Hispanic women

**Notes:**
Death is obviously the most serious consequence of domestic violence. Native women in NM were murdered at a much higher per capita rate than white and Hispanic women. 

## Female homicides in NM

- DV Was the Cause in 46% of Native American Female Homicides

## Healthcare System Consequences

- $1.8 billion per year (in 1993!)
- Victims of DV in a health plan cost about 92% more
- Utilization and costs – 1.5-2.3x greater for identified victims

**Notes:**
Just a few figures to remind us how big a burden domestic violence is on our healthcare system, too. To pick only two studies, identified victims of DV cost 92% - 230% more than other women in these healthcare plans, even when matched for factors such as age, education, and diagnoses like depression. This obviously does not account for the costs of healthcare delivery to all the women who were NOT identified as victims of DV. 
Identified victims of DV were 1.5 times more likely to utilize the system than non-victims, even when matched to appropriate controls. This may indicate that appropriate intervention could SAVE time in the long run? (Wisner ’99; Thompson, ’94-’94/’96-’97 Atlanta, ’02.)

## Kids – the “Forgotten Victims”

- “Intervention” injuries
- Bystander injuries
- Injuries to child to control mother’s behavior or hurt her
- Direct and intentional child abuse

**Notes:**
Children can also be the victims of domestic violence in several ways:
They may be injured while trying to protect their mothers, i.e. when pulling Daddy of Mom.
They may be innocent bystanders, e.g. shot while abuser was trying to shoot mother.
Threats to hurt the child may be used to control or hurt the mother.
There is an enormous overlap between domestic violence and child abuse of about 50% - that is any home with domestic violence and children has about a 50% chance of also having child abuse.

## Kids – the “Forgotten Victims”

- Custody disputes
- Long-term cognitive, behavioral and psychological effects

**Notes:**
Threats of custody disputes are a common way to control a woman’s behavior. 
The long-term effects on a child a partly due to the child’s developmental age at the time of the abuse. Difficulties with attachment, with concentration in school, and with impulse control all occur. 

## Adverse Childhood Experiences (ACE) Study

- The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences
- Survey of adults in CA HMO
- (n=9,508 adults; response rate=70.5%)

**Notes:**

This landmark study has led to a series of publications that address many leading public health issues

 For a comprehensive listing of current publications, run a search in Medline or a similar database using the key words, “Adverse Childhood Experiences.”

## Adverse Childhood Experiences

- Growing up with domestic violence
- A parent with a substance abuse problem
- A parent with a history of mental illness
- A parent with a history of criminal  behavior
- Childhood abuse and neglect

## Prevalence of ACEs

_**Household exposures**_**:****	****	****	****    **_** (%)**_
**Alcohol abuse****	****	****	****	****    23.5**
**Mental illness****	****	****	****	****    18.8**
**Battered mother****	****	****	****	****    12.5**
**Drug abuse ****	****	****	****	**** ****	****      4.9**
**Criminal behavior  ****	****	****	****  ****	****      3.4**
_**Childhood Abuse**_**:**
**Psychological****	****	****               ****	****    11.0**
**Physical****	****	****	****	****  ****	****    10.8**
**Sexual****	****	****	****	****   ****	****    22.0**

## ACEs have a graded relationship with:

- Ischemic heart disease
- Cancer
- Chronic lung disease
- Skeletal fractures
- Liver disease

## Childhood Exposure to Domestic Violence 

**↑ ****#** ACEs
- Positive, graded risk for:
- 		- **Illicit drug use**
- 		-** IV drug use**
**	****	**- **Depression**

**Notes:**

A positive grade risk means that as the frequency of witnessing domestic violence increased, the risk of experiencing alcoholism, illicit drug use, IV drug use and depression also increases

Screening for lifetime exposure to as well as current victimization is critical to clients’ long-term health

“These findings make a strong case for comprehensive screening for lifetime experience of abuse in multiple setting due to the long-term and far-reaching health implications of growing up in a home with domestic violence”

-Debbie Lee
Family Violence Prevention Fund

## Persons with 4+ ACEs had 2-4 fold risk for:

- Smoking
- Poor self-rated health
- Having 50 or more sexual intercourse partners
- Sexually transmitted diseases

## Persons with 4+ ACEs had 4-12X ↑ risk for:

- Alcoholism
- Drug abuse
- Depression
- Suicide attempts

## Guiding Principles

- Safety of victims and children
- Respect for the integrity and authority of the victim’s choices
- Perpetrators are responsible for starting and stopping violence

**Notes:**
The first principle should be familiar to all health care providers. “First do no harm.” The safety of victims and their children should guide all our actions from screening to documentation. 
Victims know how to avoid injury better than we. We need to respect this knowledge and strength, as well as her autonomy in making decisions. One of our roles is to provide information about resources, so that the patient has good information to make her own choices.
Many providers and patients can be taken in by a perpetrators excuses for his behavior. We must remind ourselves that only the perpetrator is responsible for the violence.

## Guiding Principles

- Become advocates for victims and their children
- Change the health care system to better respond to domestic violence

**Notes:**
Become advocates for change within your own healthcare facility. Listen to patients for ways to accommodate your facility to their needs when possible.

## Effective Response =Changes In:

- Screening for DV
- Assessment
- Intervention
- Documentation

**Notes:**
Effective response to DV in your clinic or office may require changes in all these areas. 

## Patient Barriers

- Phones
- Transportation
- Homelessness
- “Hypervigilant” male

**Notes:**
Patients have many difficulties in accessing the healthcare system. These difficulties may be exacerbated by DV. The perpetrator may come to clinic with the patient, and make it difficult to speak with her alone. Some facilities have an across-the-board policy that all patients will be seen alone at some point during the encounter, and this seems to work well where it is applied uniformly. Sometimes it is possible to see the patient in Medical Imaging if an Xray or ultrasound is needed. Most Imaging Departments have lots of signs stating that only the patient may go beyond a certain point. 

## Patient Barriers

- Fear
- 	- Of Violence
- 	- Losing custody
- 	- Homelessness
- 	- Losing insurance

- Finances
- Family
- Father
- Fluency
- Fondness
- Further victim-blaming
- Failure

**Notes:**
Any or all of these concerns may make it difficult for the patient to disclose DV to her healthcare provider. Any or all of these reasons may make it impossible for her to leave her abuser immediately or permanently. The patient may fear that disclosure may result in further injury to herself or her children. Abusers often threaten women with custody disputes, and leaving him may result in homelessness, or loss of income and insurance. The ideas that families should stay together, or that children need a father is very compelling for many women. Language barriers, continued love for the abuser and an unwillingness to call it quits. Many victims have had negative encounters with legal, social work or medical systems in the past, frequently being blamed for the perpetrator’s behavior, or for not protecting their children, etc.
(Thanks to Dan Sheridan, Johns Hopkins School of Nursing re: “the F words you can say in public.” 

## Patient Barriers - Medical Labels

- “Crock”
- “Hysteric”
- Borderline personality D/O
- Somatization D/O

**Notes:**
Studies have shown that over time many victims of DV are labeled negatively. When we screen for DV we may unknowingly come up against a victim’s past encounters with healthcare providers. These terms came from a review of ER records. Whether these terms were spoken to the patient’s face or not, the message still gets through. 

## Provider Barriers

- Misinformation and misconceptions
- Lack of confidence addressing DV
- Institutional barriers
- Confusion around Standards of Care
- Personal Experience

**Notes:**
Most medical providers are aware that DV is a serious problem. But many do not seem to appreciate its seriousness in both the short and long-term. Nor do we consider it a healthcare problem, rather a legal or social work issue.  We need to consider DV in the context of its effect on a patient’s other healthcare problems.
Many of us lack confidence in dealing with this issue. This is true for most of the subjects we studied in school, and is easily overcome with practice. Role-playing exercises can be very helpful in developing comfortable ways to address this issue. 
DV screening and intervention in the healthcare setting is no longer an option, or a nice thing to do if we have time. Requirements of GPRA, JCAHO, as well as recommendations from many specialty boards constitute an expectation and a standard of care. These arguments have been successful in some court cases. 
Time, space, fear of embarrassing the patient. IHS DV Survey – overlap betw. 
DV is so common, that many staff - medical, nursing, all staff – have experienced or observed this in their own families. EAP programs may be helpful for some of these folks.

## MD-specific Barriers

- CME’s
- Mandatory reporting requirements
- “Competing public health agenda”

**Notes:**
DV training of healthcare providers is often and appropriately done with other professions such as nursing and social work. But this may cause difficulty in getting Medical Provider CME for DV trainings, which may affect turnout for these trainings. You may need to offer separate CME’s for medical providers in order to get around this barrier to poor turnout.
Confusion about mandatory reporting of DV is especially common in I/T/U facilities. Your state may have reporting requirements, which may or may not conflict with tribal reporting requirements if your facility is on a reservation. Seek help from your Area’s legal counsel in answering these questions.
Some providers may see DV issues as just “one more thing” to do. The argument is that screening for cervical cancer, alcoholism, diabetes, hypertension are all important and have proven interventions, so should receive more attention and time. DV affects all aspects of a woman’s health. Knowledge of this issue is essential to proper care of any patient, and effective office interventions are available, even if resources for DV in your community are scant, and even if the woman will not make a change at this time. 

## GPRA FY 05Domestic Violence Indicator # 15

- The IHS will ensure that
- 15% of women
- Ages 12 and older are screened for** **DV

## Clinical Objectives

- Adult females should be screened for DV at the initial encounter and then at least annually
- Prenatal patients should be screened once each trimester

## Documentation of DV Screening Using RPMS

- DV screening will be conducted as an “Exam” within a visit
- Screening can currently be documented in SOAP notes or elsewhere on PCC (stamp, pre-print), however, this cannot be coded by Data Entry

## DV Screening Using RPMS

- DV screening will be conducted as an “Exam” within a visit
- Document DV/IPV screening results  on PCC form under POV or electronically in BH application

## Allowable DV/IPV Screening Exam Results:

- “Normal/Negative” – denies being a current or past victim of DV
- “Present” – acknowledges being DV victim w/in past 12 months
- “Past” – acknowledges being DV victim in past (>12 months ago)
- Refused – patient declined exam/screen
- Unable to screen (document reason)

## Allowable DV/IPV Screening Exam Results:

- “Abnormal” cannot be entered
- Even though it’s an option!

## Exam Code #34’s entry into RPMS

- _WHEN A PATIENT HAS BEEN SCREENED FOR DV_
- Enter “Mnemonic”
- Then “Exam”
- Then “34”
- If patient screened POSITIVE screen for DV, then enter/select PR (“present”) or PA (“past”)
- If NEGATIVE screen for DV,  then enter/select “Normal/Negative”
- A (“Abnormal”) cannot be entered, even though it is listed as an option!

## Exam Code #34’s entry into RPMS

- _WHEN DV SCREENING IS CONSIDERED BUT NOT OFFERED_
- Enter “Mnemonic”
- Enter _UAS_ (“Unable to Screen”)
- Then “Exam”
- Then “34”
- Use (DOS) as date of unable to screen

## Exam Code #34’s entry into RPMS

- _WHEN DV SCREENING IS CONSIDERED BUT NOT OFFERED_
- Enter “Mnemonic”
- Enter REF (“Refused”)
- Then “Exam”
- Then “34”
- Use (DOS) as date of unable to screen

## Exam Code #34’s entry into RPMS

- No space for Narrative in any of these fields at this time
- Stay tuned

## Screening Tips

**Privacy**
**Physical position**
**Limits of confidentiality**

**Notes:**
Many women need reassurance re: the location of confided information and that her participation is voluntary. It may be helpful in smaller facilities to tell the patient which clinic staff will be privy to the information she discloses.
Providers, especially men, should consider their appearance to the patient. Sitting on a low stool  and speaking softly may be helpful. 
Limits to confidentiality should be discussed with the patient. E.g. Mandatory reporting requirements; Threats to life or limb; Use of weapons; Child Abuse.

## Screening Tips

**Explain routine screening**
**Interpreters**
**Concentrate on what happened, not why**
**Emphasize concern for safety**
**Respectfully use patient’s words**

**Notes:**
It is often helpful to explain the routine nature of the screening. Some women may otherwise wonder why they’ve been singled out for these questions.
Interpreters are often needed. This is especially true when discussing emotional issues. Consider offering the services of an interpreter, but make sure the patient is OK with  the interpreter. They may know each other.
Concentration on the abuse may help the patient to see these events more objectively. It is also a way to assess the severity of the abuse and the danger to your patient. 
DV is never acceptable. Your patient may wish to explain why these events occurred, but do not concentrate on these “reasons.” Or use this opportunity to point out the inadequacy of these excuses. E.g. “It is not OK for your husband to hit you when he’s stressed at work. If it’s not OK to hit his boss, then why is it OK to hit you?” 
Concern for her safety is the primary reason for these interventions. Emphasizing this will help her talk about the abuse, and worry less about what your agenda for her may be. 
Use the patient’s own words: e.g. boyfriend or husband. She may not see herself as a “victim of abuse” or “domestic violence” and not care for this terminology.

## Sample Approaches

- Frame the question
- Ask the question!
- Matter-of-fact approach

**Notes:**
It is important to frame the question, even if your abuse assessment screen is written. 
We may be more comfortable talking about the general problem of abuse, and never get to asking our specific patient.

## Suggested Screening Questions

- “Because violence is so common, I ask all patients...”
- “I am concerned that your sxs may have been caused by someone hurting you.”
- “Many patients I see are dealing with abusive relationships.....”

## Suggested Screening Questions

- Are you in a relationship w/ someone who hurts you or threatens to hurt you?
- Did someone cause these injuries? Was it your partner?
- Is it safe for you to go home?

## Patient Denial Of DV

- Accept response
- Keep door open
- Offer information for patient to pass on to family/friends

**Notes:**
Patients may not feel safe disclosing DV, despite your best efforts. Remind them that this is an issue that they can discuss anytime, with you or with others who want to help. 
One approach is to offer the information for patient to share with family and friends. This often takes the pressure off her to disclose, and you can still get some information across. Remember, our primary concern is to increase safety, not necessarily to obtain disclosure. 

## DV Assessment

- Time for assessment
- Where is perpetrator now?
- Pattern and Hx abuse
- Connect DV and health issues
- Patient’s access to advocacy and support
- Children
- Review medical record

**Notes:**
TIME: You and your patient may not have enough time to cover all these issues in onve visit. If the perpetrator is in the waiting area, or expects the patient to be home by a certain time, then you may need to move more quickly to your intervention. 
Your patient may not see the connection between DV and her health issues. Make these connections clear. A review of the medical record may help make these connections even clearer to the patient and to the you.

## Lethality Assessment

- WEAPONS – access and past use
- ESCALATION in frequency and severity
- HOSTAGE and/or STALKING
- HOMICIDAL or SUICIDAL THREATS

**Notes:**
The presence of any of these factors increases the risk of injury and death. 
A history of repeated episodes of abuse without consequences may heighten the abuser’s sense of immunity and justification. It may also explain a woman’s reluctance to avail herself of certain services.
The use of alcohol/drugs increases the risk of injury, whether intentional or unintentional (in the sense that he hurts her more than he intends to). But many women become more fearful when the abuser is sober. “He usually beats me when he’s drunk, but this time he was stone-cold sober. That really scares me.” 
Children can be injured in domestic violence in several ways. Threats or actual injury to children may be a very effective way to control the woman’s behavior. Children may be hurt as bystanders, e.g. he shoots at her and misses, hitting the child. Children may be hurt while trying to intervene, e.g. trying to pull the abuser off the woman. And the child may be the direct target of abuse, too. There is enormous overlap between DV and child abuse. It’s estimated that child abuse occurs in 40-50% of homes where there is DV, and vice versa.

## Lethality Assessment

- Use of ETOH/other DRUGS
- PUBLIC DISPLAYS of violence
- Past abuse – consequences
- CHILDREN

**Notes:**
The presence of any of these factors increases the risk of injury and death. 
A history of repeated episodes of abuse without consequences may heighten the abuser’s sense of immunity and justification. It may also explain a woman’s reluctance to avail herself of certain services.
The use of alcohol/drugs increases the risk of injury, whether intentional or unintentional (in the sense that he hurts her more than he intends to). But many women become more fearful when the abuser is sober. “He usually beats me when he’s drunk, but this time he was stone-cold sober. That really scares me.” 
Children can be injured in domestic violence in several ways. Threats or actual injury to children may be a very effective way to control the woman’s behavior. Children may be hurt as bystanders, e.g. he shoots at her and misses, hitting the child. Children may be hurt while trying to intervene, e.g. trying to pull the abuser off the woman. And the child may be the direct target of abuse, too. There is enormous overlap between DV and child abuse. It’s estimated that child abuse occurs in 40-50% of homes where there is DV, and vice versa.

## Physical Exam

- Directed Physical Exam
- If injuries, note patterns, various stages of healing, etc.
- STD concerns – consider S.A.N.E. if available
- Preservation of Evidence

**Notes:**
The physical exam may prove the easiest part of DV evaluation. 
Look for patterns of injury, and if found, note them as such. 
Address STD concerns. The provider is often the one who needs to bring this up. If available and patient is willing, consider referral to a Sexual Assault Nurse Examiner.
Find out what procedures your institution has – if any – for the preservation of evidence and the chain of evidence, if the patient wishes to file charges. Consider referral to another facility that can maintain a chain of evidence, if your facility cannot. 

## Intervention/response

- What’s the point?
- For her to go?
- Or to be safer?
- Who’s agenda?

**Notes:**
Remember the guiding principles when formulating your response to the disclosure of DV. Your job is to promote safety, while respecting her autonomy and decisions.

## Intervention/response

- LISTEN and VALIDATE
- LISTEN and SUPPORT
- LISTEN and ADDRESS SAFETY ISSUES
- LISTEN and PROVIDE INFORMATION RE: RESOURCES
- LISTEN and REFER
- Discuss follow-up

**Notes:**
LISTEN. This may be the first time the patient has disclosed DV. This is therapeutic in and of itself.
Validation is treatment. Your patient may never have heard statements like: “No one deserves to be treated this way.” “There are people available to help you with this problem when you wish.” These statements are even more significant coming from a person in a position of authority, such as a health care provider. 
Address safety issues: Ending relationship is the most dangerous time of that relationship. On the other hand, she needs to know that the violence will probably increase in frequency and severity over time. Patients are frequently unaware of community resources and your clinic’s resources. 
Refer patient to other assistance (e.g. advocates, SW, BH, legal) as she desires. Note that women randomly assigned to receive community advocacy services were much less likely to experience violence during the study period. 
DV requires multiple interventions over time – like DM, smoking or most other health issues.
Discuss follow-up with patient. Attend to wishes, as well as what she’s able to do. 

## Safety Planning

- Lifetime Channel
- Memorize important phone numbers
- Teach kids to dial 911/other numbers
- Keep change or phone card at all times
- Open own bank account

**Notes:**
A 10 minute intervention such as this has been shown to increase a woman’s safety behaviors.

## Safety Planning – Cont’d

- Stay in touch with friends
- Rehearse escape plan
- Extra keys
- Extra $
- Extra clothes
- Kids’ school, medical and immunization records

## Safety Planning – Cont’d

- CIB, other id (driver’s license, Medicaid,...)
- Bank books, titles, insurance, lease papers
- Important addresses and phone numbers

## Safety Planning – Cont’d

- Change locks
- Home security devices: alarms, metal doors, smoke detectors, outside lights
- Inform neighbors, apartment staff, supervisors and coworkers
- School/daycare directions re: who can pick up kids
- Restraining Order
-  Avoid old “haunts”

**Notes:**
Safety planning for once she’s been able to leave or get out.

## Documentation

- Clinical care
- Medical/legal issues
- Patient’s legal issues

**Notes:**
Documentation is important for several reasons. 
Communication of this important health problem w/ other providers who may see patient in the future.
Doctors and hospitals have been sued for not identifying or appropriately intervening in DV. Good documentation is our best defense against malpractice suits. This is just as true for documentation of DV as it is for any other issue. 
Your documentation may assist the patient’s current and future legal proceedings.

## Documentation Elements

- Legibility/completeness
- H&P
- Labs/X-rays
- Safety Assessment
- Body maps
- Photographs
- Options/Referrals

**Notes:**
The ideal chart entry.

## Documentation - cont’d

- “Excited utterances”
- “Injuries inconsistent with the hx given.”
- Wording of notes and referrals

**Notes:**
Document in the patient’s words whenever possible. 
If you strongly suspect abuse, but the patient does not disclose, then a note about the inconsistency is acceptable, without arguing with the patient.
The wording of chart entries and referrals can be used against the patient, e.g. in custody disputes. 

## Slide 60

**Notes:**
These are forms HIS provides for various purposes. 
We are required to obtain written permission before photographing patients. This is the form IHS provides. It’s approval as an official form is pending, therefore it has no number.

## IHS-523

**Notes:**
Form HIS-523 for placement of photographs in chart.

## SF 531

**SF 531**

**Notes:**
Form SF531 Body map.

## Slide 63

## Conclusion

- Increase safety is goal
- Support victims in protection of themselves and their children

**Notes:**
DV screening, assessment, intervention and documentation is DOABLE, even when time is short. 
Communicate NO EXCUSE for DV, she’s not alone, you and others care.
Respect her and her decisions.

## % SCREENED/% + SCREENS

## # PREGNANT/% SCREENED

## # POV DVDX “DIAGNOSIS”