The author(s) shown below used Federal funds provided by the U.S. 

Department of Justice and prepared the following final report: 

Document Title: An Intervention to Improve Documentation of 

Intimate Partner Violence in Medical Records 

Author(s): V. Pualani Enos, Judith A. Linden, Lisa Tieszen, 

Judith Bernstein, Jody Brown 

Document No.: 207146 

Date Received: October 5, 2004 

Award Number: 2000-WT-VX-0014 

This report has not been published by the U.S. Department of Justice. 

To provide better customer service, NCJRS has made this Federallyfunded grant final report available electronically in addition to

traditional paper copies.

 

Opinions or points of view expressed are those 

of the author(s) and do not necessarily reflect 

the official position or policies of the U.S. 

Department of Justice.
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 

RESEARCHER-PRACTITIONER PARTNERSHIP MEMBERS.............................................................2

ACKNOWLEDGMENTS................................................................................................................................3

EXECUTIVE SUMMARY..............................................................................................................................4

INTRODUCTION ..........................................................................................................................................16

LITERATURE REVIEW..............................................................................................................................18

STATEMENT OF THE PROBLEM.......................................................................................................................18 

BACKGROUND AND SIGNIFICANCE OF THE RESEARCH...................................................................................21 

PRIOR WORK...............................................................................................................................................26

BUILDING A PRACTITIONER-RESEARCHER PARTNERSHIP TO RESEARCH DOCUMENTATION OF DOMESTIC 

VIOLENCE IN HEALTH CARE SETTINGS .........................................................................................................26 

EXECUTIVE SUMMARY OF THE PRIOR RESEARCH ..........................................................................................26 

BUILDING ON THE FINDINGS OF THE PREVIOUS RESEARCH ...........................................................................30 

EVIDENTIARY CONSIDERATIONS ...................................................................................................................33 

DEVELOPING, IMPLEMENTING AND EVALUATING A DOCUMENTATION TRAINING........39

OVERVIEW.....................................................................................................................................................39 

CURRICULUM DEVELOPMENT........................................................................................................................40 

DELIVERING TRAINING TO PROVIDERS AT THREE SITES................................................................................66 

POST-INTERVENTION RECORD REVIEW .........................................................................................................68 

POST-INTERVENTION FOCUS GROUPS............................................................................................................75 

TRAINING FOR ADVOCATES WORKING IN HEALTH CARE SETTINGS...............................................................89 

LESSONS LEARNED & RECOMMENDATIONS ...................................................................................91

CONCLUSION...............................................................................................................................................95

REFERENCES ...............................................................................................................................................99

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 2 

Researcher-Practitioner Partnership Members 

Principal Investigator: V. Pualani Enos, JD 

Assistant. Clinical Professor Research Coordinator, Ke Ala Lokahi 

Domestic Violence Institute School of Social Work 

Northeastern University School of Law University of Hawaii, Manoa 

716 Columbus Ave., Suite 212 1600 East-West Road 

Roxbury, MA 02120-2111 Honolulu, HI 96822 

Tel: (617) 373-4972 Tel: (808) 268-9184 

email: pualanienos@hawaii.rr.com; p.enos@neu.edu

Co-Investigator/Site Coordinator/Curriculum Team Member: Judith A. Linden, MD 

Assistant Professor & Attending Physician Tel: 617.414.4537 

Department of Emergency Medicine email:jlinden@bu.edu 

Boston University School of Medicine 

818 Harrison Ave. 

Boston, MA 02118 

Co-Investigator/Site Coordinator/Curriculum Team Member: Lisa Tieszen, LicSW 

Beth Israel Deaconess Medical Center Tel: 617.667.8241 

Center for Violence Prevention and Recovery e-mail: ltieszen@caregroup.harvard.edu 

330 Brookline Ave. 

Boston, MA 02215 

Senior Research Consultant: Judith Bernstein, RNC, PhD 

Associate Professor of Maternal and Child Health Tel: 617.414.1415 

Boston University School of Public Health e-mail: jbernste@bu.edu

Associate Professor of Emergency Medicine 

715 Albany St., T5W 

Boston, MA 02118 

Senior Research Consultant: Jody Brown, PhD 

Research and Evaluation Consultant Tel: 401.783.8318 

On Family Violence e-mail: j.brown@uri.edu

3 Diane Drive 

Kingston, RI 02881 

Curriculum Development Consultant: Elaine Alpert, MD, MPH 

Associate Professor of Public Health Medicine 

Boston University School of Public Health Tel: 617.638.4118 

715 Albany St., T5W e-mail: ealpert@bu.edu 

Boston, MA 02118 

On-Site Consultants

Dan White Joan Sham, RN 

Boston Emergency Medical Services Boston Medical Center, Emergency Medicine 

Carrie Tibbles, MD 

Susan Pacheco, RN 

Beth-Israel Deaconess Medical Center, Emergency Department

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 3 

Acknowledgments 

We owe a great debt to the intimate partner violence (IPV) survivors who participated in this project. 

We would like to express our gratitude to the women and men who shared their IPV related experiences in 

health care settings. Their willingness to describe their experience, share insights and contribute concrete 

strategies and suggestions enabled us to construct trainings that dispelled myths, identified mistakes 

commonly made by medical providers, and suggest new strategies to accommodate a variety of patients. 

The research design and training developed for this project as well as the overall conclusions and 

recommendations for this project are grounded by their opinions, perspectives and suggestions. We also 

thank the advocates and social workers working within IPV service organizations that assisted us to make 

direct contact with survivors. 

This project would not have been possible without the cooperation and participation of the staff at all 

three sites involved in this project. We thank them for their time and willingness to share their experiences 

to help us to learn about the practical workings of each department and the potential of each to respond 

more effectively to intimate partner violence. Providers’ willingness to discuss their practices and opinions 

candidly enabled us to create training that more accurately addresses their concerns and needs. 

Additionally, we appreciate the participation of the legal, risk management and medical records 

departments of various local hospitals that allowed us to accurately respond to the concerns and obstacles 

raised by medical providers in our training. 

We want to recognize the hard work and commitment of the public health research assistants, 

Annette Brien, Karen Malme , Carolyn Rahn and Meg Stone, who had the tedious job of carefully 

reviewing thousands of difficult-to-read medical records. Meg Stone also conducted several nurse training 

sessions and played a central role in scheduling, conducting and transcribing pre-training focus groups. 

We would also like to thank our legal research assistants, Jennifer Bombard, Meghan Boyle, Jennifer 

Cynn, Jessica Foley, Keren Goldberg, Pam Griffith, Lindsey Johnston, Kathrina Peterson, and Moira 

Sullivan. Our appreciation also goes to Jane Doe, Inc. for working collaboratively with us to investigate 

legal requirements relating to confidentiality, privilege and liability issues for providers responding to IPV. 

Findings issues in a report authored by Northeastern University School of Law’s Law, Culture and 

Difference Law Office 10 greatly supplemented our legal research findings. Finally, we thank Arleen 

Ricalde-Garcia for several hours she contributed to editing this report. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 4 

EXECUTIVE SUMMARY 

Goal. Medical documentation regarding intimate partner violence, and testimony based on that 

documentation, are valuable tools for victims seeking legal relief from abuse. Inadequate documentation 

practices and under-utilization of medical records by attorneys currently hinder victims’ efforts to secure 

legal relief. In this project we developed, implemented and evaluated an intervention designed to improve 

the abuse documentation practices of health care providers, by encouraging them to apply diagnostic and 

documentation skills traditionally understood to fall within the medical realm of professional competence 

and responsibility. 

Health care professionals commonly encounter intimate partner violence (IPV) when caring for 

patients. Recent health care provider training has focused on screening, identification of IPV, and social 

service interventions for battered women. While providers are encouraged to identify and assist victims of 

IPV for services, focus groups and a review of training manuals and IPV protocols from around the United 

States reveal that providers rarely receive any direction regarding how and why to document IPV. While 

providers may be trained in screening and assessment, few who have received any training related to 

documentation of the assessment and treatment provided (Davidson, 2001). Providers have identified 

several issues that discourage them from documenting IPV in patient charts. These include: (a) not 

recognizing how helpful corroborative or direct documentary evidence of abuse may be to patients seeking 

protection, (b) misplaced fear that documentation can only increase provider’s risk of medical malpractice 

liability, (c) belief that documentation of IPV can only hurt the patient if anyone outside of the health care 

setting views the record, (d) belief that documentation will increase the likelihood of being called to testify 

in court, and (e) lack of specific training regarding time efficient documentation of injuries, patient 

statements and observations. 

Many patients who seek health care for injuries related to IPV eventually access legal means to 

achieve violence-free lives. Legal remedies include prosecuting abusers, obtaining abuse prevention 

orders, seeking custody of and visitation with children, applying for benefits and housing privileges, and 

securing immigration rights. Medical records that document abuse can make the difference between 

success and failure in obtaining any of these forms of relief. Currently, however, many attorneys do not 

utilize medical records in these contexts. Reasons for not using the records include (a) difficulty and 

expense in obtaining records, (b) illegibility, incompleteness or inaccuracy, of documentation and (c) the 

possibility that the information in records, due to these flaws, may be more harmful than helpful. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 5 

The current project builds upon the previous work of a unique medical-legal, researcher-practitioner 

collaboration. The prior project, hereinafter referred to as Legal Evidence Project 2002, explored the 

utility of abuse related medical records in legal proceedings, revealed the concerns and problems 

associated with documenting IPV in health care settings and made recommendations as to how providers 

should document IPV. Originally, the current project was designed to improve providers’ documentation 

skills in order to improve the quality and continuity of care and provide patients with useful corroborative 

evidence of the health impacts of abuse. As a means of achieving this goal, we intended to develop a 

training program focused primarily on documentation of IPV. However, once we began investigating the 

current practice in each of our study settings, we concluded that focusing on documentation without first 

addressing assessment and response to IPV would be impossible given the frequency and quality of 

response to IPV in the three settings. In order to accomplish our primary goal of developing an 

intervention to improve documentation we needed to perform two additional tasks. We needed to develop 

a response to IPV that addressed the needs of the providers in each setting. At the same time, we needed to 

explore what structural changes and administrative resources were needed to support implementation of 

such a response. Once these additional tasks were accomplished, the research team developed a training 

that presented a recommended response to IPV that emphasized documentation, employed a patient 

empowerment model and relied on an interdisciplinary team approach. 

Curriculum Development. In order to inform the development of the three training curricula for 

each of the study groups, we conducted focus groups with emergency medical technicians (EMTs), 

paramedics, nurses and residents from each study site. We also conducted separate focus groups with IPV 

survivors, IPV advocates, social workers, and hospital administrators. Hospital administrators included 

management staff from legal, risk management and medical records departments of area hospitals. 

Records from each site were reviewed for a three-month period prior to training delivery to supplement the 

record review conducted in our previous NIJ-funded project. IPV health care protocols and related 

literature were reviewed to determine current strategies relating to assessment and documentation. A 

thorough legal literature review augmented the findings from our previous projects on liability and patient 

privacy issues. Using this data, our curriculum development team formulated a 50-minute training for each 

provider group using a team-based approach that describes the benefits of a health care response to IPV, 

presents concrete strategies for assessment and documentation of IPV, and details a limited intervention 

that all provides can deliver within a five-minute interaction regardless of patient disclosures or readiness 

to take action. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 6 

Initial Focus Group Results. We conducted 10 focus groups with providers, 7 focus groups with 

survivors, six focus groups with hospital administrators and 20 interviews with providers, administrators, 

advocates and social workers from health care institutions that were not involved as study sites. Results 

from the focus groups provided valuable insights relating to what types of medical interventions are helpful 

and harmful to patients experiencing IPV and issues relevant to IPV that need to be addressed in order to 

prepare providers to respond to IPV. 

Helpful medical interventions include: 

 Providers who treat clients with care and respect. 

 Providers sharing resource information for services that can be accessed subsequent to treatment. 

 Medical record management that maintains patient privacy and confidentiality 

 Recording abuse related information can be extremely useful to patients and may be the only outside 

account of the abuse. 

 Patients want providers to recognize signs of abuse and inquire about abuse in a sensitive and private 

manner. 

 Providers telling patients that help is available and change is possible without pressuring patients to take 

action. 

 Providers who do not condition careful assessment of health condition or comprehensive treatment on the 

patient’s willingness to disclose abuse. 

 Health care institutions creating a safe environment for gay, lesbian, bisexual and transgender patients in 

abusive relationships. 

 Provider recognition of how dangerous it is for most victims to seek any kind of help, including medical 

care, related to IPV. 

Potentially harmful medical interventions include: 

 Providers pressuring a patient to follow their advice to “leave the relationship,” “call the police,” or “get 

a restraining order.” 

 Providers underestimating the patient’s own understanding of the danger posed to her and her children. 

 Providers becoming angry, distant or blaming of patients who do not take recommended action steps 

 Providers pressuring patients to disclose abuse or to retell incidents of abuse to multiple providers during 

the same visit. 

 Health care institutions and providers failing to provide full protection of medical records and 

information related to treatment. 

 Providers inadvertently placing patients in more danger through taking action that exposes patients’ helpseeking to abusive partners. 

Areas of inquiry for further exploration by institutional interdisciplinary teams include: 

 What resources are necessary to implement an effective response to IPV in each department of the 

institution? 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 7 

 What kind of training do providers in each department require and how can that training be tailored to 

meet the needs and resources of each department? 

 What types of services must be referred outside of the institution? 

 How can the institution and individual providers better protect patient privacy, confidentiality and 

privilege and thereby decrease vulnerability to legal liability? 

Training Implementation. A training curriculum for each of the provider groups at the three sites 

was developed using data collected in the focus groups, results from the literature review, and the pretraining record review. Several trainings were offered over a period of two-three months in an attempt to 

capture 70% of the providers at each site. We were successful in training 237 EMTs and paramedics 

(78%) at the Pre-hospital site; 48 nurses (80%) and 23 residents (59%) at Emergency Department Site #1; 

and 41 nurses (51%) and 16 residents (57%) at Emergency Department Site #2. 

Medical Record Review. At the pre-hospital site, 48 records of IPV from the pre-training period 

and 70 from the post-training period were examined. At Emergency Department Site #1, 59 records of 

IPV cases from the pre-training period and 48 IPV records from the post-training period were examined. 

Intake, nursing and resident notes from each record were reviewed. At Emergency Department Site #2, 16 

records of IPV cases from the pre-training period and 20 IPV records from the post-training period were 

reviewed. Due to the small number of records identified at Site #2, the pre- and post-training records, 

including intake, nursing and resident notes, are described qualitatively while the pre- and post-training 

records from the pre-hospital site and Emergency Department Site #1 were compared using Chi-square 

methods. 

Overall, our findings related to the effectiveness of the training remain inconclusive due to the small 

number of IPV records written by providers who had attended the training. While some changes in 

charting practices did occur and it appears that attending the training may increase provider identification 

of IPV, further study of the intervention is needed to fully ascertain its potential. However, we did collect 

informative data relating to current practices of providers, needs for resources and support to respond to 

IPV, and means to overcome obstacles and challenges to respond to IPV. Data collected from survivors, 

advocates and social workers also illuminated the benefits of interdisciplinary teams and implementing a 

team approach to IPV in medical settings. Information collected from legal, risk management and medical 

records staff working in hospital settings also reveal the importance of involving these departments when 

developing IPV protocols and policies. The evaluation speaks to the feasibility of IPV training in an 

emergency medical setting and the challenges related to evaluating provider practices. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 8 

Lessons. Several valuable lessons emerged over the course of this project. We have selected several 

lessons to share and made recommendations for future work and replication efforts. 

Lesson One: 

Most providers easily recognize physical symptoms related to IPV. Providers 

struggle with how to talk to patients who disclose abuse and how to deal with 

patients who present with symptoms but do not disclose abuse. Providers may 

become so focused on avoiding IPV or investigating it that they run out of time 

to do what they are most qualified to do: assessing, treating or documenting 

the patient’s medical needs. 

Recommendations: 

 Providers need direction in how to talk to patients about abuse, the 

impacts of abuse on the patients’ health and how to limit the scope of 

inquiry so that they can attend to medical needs. 

 Providers need to remember to conduct thorough assessments of past, 

potential and current injures, treat all injuries and better document 

observations rather than focusing all their attention on collecting details 

of an incident, safety planning or referring patients to IPV services. 

 Providers must understand that it is not their responsibility to ‘make a 

patient safe’ or solve her problems. Providers can play an important 

role by educating patients that help and resources are available, 

breaking patients’ isolation, build patients’ trust in helping systems and 

creating a positive help-seeking experience.

 Providers need more training in how to recognize psychological and 

emotional abuse and how this type of abuse impacts a patient’s 

physical and mental health and her ability to manage health care issues.

Lesson Two: 

The feasibility of implementing an IPV protocol, delivering training related to 

the protocol and evaluating provider adherence to the protocol is dependent 

upon adequate resources and department-wide support. 

Recommendations: 

 Department resources must be carefully evaluated in order to assess the 

best means of implementing an IPV response. 

 To maximize limited training resources, training sessions should be 

offered to as many providers as possible at the same time. However, 

obtaining full department participation may require offering several 

trainings at varying times to accommodate provider work schedules. 

Significantly more resources are necessary to implement a protocol in a 

24-hour setting than one that operates during regular business hours. 

 Administrative support for participation in trainings and implementing 

protocol practices in the form of monetary compensation and 

professional recognition would greatly enhance training participation 

and protocol implementation. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 9 

Lesson Three: 

Implementing a team approach to respond to IPV in health care settings 

enables providers to use their medical skills to support victims and do so 

within their time and resource constraints. 

Recommendations: 

 Providers should provide a limited intervention that includes: 

 Inquiring in a kind and private way about symptoms or 

presentations that raise a concern of IPV; 

 Performing a careful assessment of all symptoms and 

conditions not just the most serious injury; 

 Inquiry into the healing of past injuries 

 Treating all medical conditions; 

 Documenting any patients descriptions of incidents of abuse 

resulting in need for medical care including facts relating to 

who, what, where, when, how, type of force and any weapons 

used. Quotes and “patient reports” is the recommended means 

of documenting the patient’s description of events. 

 Documenting injuries and health conditions in a detailed and 

specific manner. Providers may have to draw their own body 

maps. Photographs are recommended if they will be sufficiently 

protected and stored with the medical record or given to the 

patient or patient advocate. 

 Counseling, safety planning and advocacy work should only be 

performed by providers or others who have received extensive formal 

training in IPV. 

 Providers need to plan for patient and provider safety during patient’s 

stay in the institution. Providers should involve security personnel in 

safety planning rather than waiting until a problem arises. 

 Providers can indicate to patients that help is available, that change is 

possible and offer resource numbers and referrals to IPV services in a 

five-minute intervention. 

Lesson Four: 

Many providers feel that they do not have the time or resources within the 

treatment setting to solve the problem of IPV. Most providers only consider a 

response effective if it achieves patient safety upon discharge. Such high 

expectations are unrealistic given the complicated nature of IPV. 

Recommendations: 

 Modifying expectations to create more realistic goals to achieve an 

effective response to IPV is necessary. 

 A team approach to IPV in health care settings will optimize limited 

resources. 

 Providers who conceptualize themselves as a part of a team of service 

providers are more likely to see the potential for successfully 

responding to IPV.

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 10 

Lesson Five: 

General Protocols developed by organizations or outside health care 

institutions serve as useful templates for devising a protocol but it must be 

tailored to meet the circumstances, needs and resources of each particular 

setting. 

Recommendations: 

 A thorough exploration of current workings and procedures, including 

forms and electronic record keeping systems, must inform any protocol 

related to IPV. 

 Providers with extensive experience working in the setting are vital to 

the development of a working protocol. 

 Patients should also be consulted for recommended responses. 

 Relevant administrative offices including legal counsel, social work 

and medical records departments should be involved in developing the 

protocol. 

 Protocols should incorporate local resources.

Lesson Six: 

Medical documentation is not necessarily standardized among providers, even 

within the same department. Many medical record forms are not user friendly 

in cases of IPV and do not provide for photograph storage. 

Recommendations: 

 Standardizing documentation methods would improve patient records 

by clarifying what occurred at each visit. 

 More consistent documentation strategies could only increase the 

quality and continuity of care. 

 Providers within departments or institutions should adopt a list of 

abbreviations that everyone could use. A legend depicting commonly 

used abbreviations would greatly increase the likelihood that records 

could be introduced into court without requiring that a provider 

interpret the records. 

 Medical record forms should be constructed to make response to IPV 

easier to document. A storage place for photographs and releases 

should be provided.

 Providers should be informed of rules governing their release of 

information related to patient treatment. Providers should also be 

familiar with rules and procedures relating to how their health care 

institution manages and protects patient records. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 11 

Lesson Seven: 

Many of the providers involved in the study believe that if an IPV intervention 

cannot be executed fully from beginning to end with a patient, the provider 

should avoid the issue of IPV altogether. Many of the IPV training manuals 

and protocols may inadvertently reinforce this message. 

Recommendations: 

 It is better for providers to perform one step of an intervention than do 

none at all. Simply acknowledging abuse is important. 

 Most patients are not expecting and may not want extensive services 

from a health care setting. Perhaps only certain aspects of an 

intervention will suit a patient’s needs. Responding to each patient’s 

unique circumstances is likely to encourage her or him to seek help 

again in the future. 

 The quickest and easiest intervention for providers is to leave a card 

with resource numbers in a place where patients can review them in 

private and take them home without notifying hospital staff. Many 

patients prefer to receive resource numbers in this private manner. 

 Most areas have a 24-hour hotline that IPV victims can call 

anonymously to talk to a trained IPV counselor. Providers without the 

time or skills to address IPV should provide patients access to a phone 

in a private room so they have an opportunity to make this call.

Lesson Eight: 

A 50-minute training to a portion of the staff is not enough training to create 

significant change in how a medical site addresses IPV. Additional training 

time would better able trainers to address training priorities more fully. 

Recommendations: 

 Providers would be more likely to adopt practices if all providers were 

required to attend training, incentives to acquiring knowledge and skills 

were made available, and structural changes to procedures and medical 

records could be made to accommodate provider concerns. 

 Training needs to be on-going and conditions that reinforce 

implementing knowledge and skills into practice needs to be 

established. Further study and thought should be given to training 

methods other than in-service group sessions. Alternatives could 

include: 

 Small group record reviews 

 One-on-One clinical consultations during work shifts 

 Partnering with a domestic violence advocate to deliver services 

on a case-by-case basis 

 Training should be delivered to all staff, and it may be more effective 

to train across provider groups, preferably training providers who 

regularly work together as a team. 

 Future studies should incorporate mechanisms to ensure maximum 

feedback from study participants as to usefulness of the training after 

some period of implementing intervention strategies. 

 Further study of how to sustain effects of training and to continue to 

improve documentation processes is needed.

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 12 

The Need for Institutional Support in Addressing IPV. Many helpful protocols, guidelines and 

training manuals are available to assist health care providers to develop more effective strategies for 

addressing IPV. Resources have been tailored to address different types of practice settings and the 

varying roles played by different types of providers. However, despite the tremendous effort devoted to 

improve health care response to IPV, current practice in most medical settings need to undergo significant 

changes in order to confront the health impacts of IPV through consistent identification, careful 

assessment, and comprehensive treatment of injuries and health related symptoms that result from IPV. 

A review of this report and any protocol, guidelines or training manual addressing health care 

response to IPV reveals that providers are being asked to make substantial changes in the way they 

currently address patients presenting with IPV. Many providers, like professionals in so many other 

disciplines, did not choose to specialize in IPV work but instead have been thrust into it as a result of their 

chosen area of interest whether it is medicine, law, social work, or psychiatry. While they may prefer to 

avoid issues such as IPV, child abuse and neglect, elder abuse and other violent crimes it will inevitably be 

a part of their work. Accordingly, if providers are expected to adopt new approaches and implement them 

into their every day practice, they must be given adequate resources, support and training. In order to 

effect changes in provider behavior, institutions must recognize the needs of providers, develop approaches 

and practices that make sense within each treatment setting, and make structural and institutional changes 

to support recommended practices. 

First, health care administrators who control budget decisions must also recognize how regularly 

providers may see patients experiencing IPV and acknowledge the resources necessary to properly respond 

to this problem. Resources include ongoing clinical training, access to private treatment rooms in a 

secured area, working partnerships with other relevant services within the health care setting (security, 

social work, IPV advocates, interpreters) and referral mechanisms to services outside the health care 

setting (IPV support groups, safe housing, police and legal advocacy programs.) 

Next, institutions must coordinate designated persons from relevant departments within the institution 

to design a response to IPV for various departments that best suits the needs, circumstances and resources of 

each department. Creating an interdisciplinary working team made up of health care providers delivering 

direct services, legal counsel, risk managers, and medical records staff will increase the likelihood of 

devising a response that will work and protect providers and the institution from any liability or unnecessary 

costs. (Brouhard & Mahoney, 2002) When developing a response, institutions must also consider creating 

partnerships with services outside of the hospital in order to supplement their own resources. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 13 

Finally, the institution must implement the plan through infusing money and personnel resources 

where appropriate, making structural and systems modifications where necessary, working with providers 

to acquire the skills necessary to incorporate the IPV response into their practice and maintaining positive 

relationships with service partners outside the hospital. 

When developing an IPV response institutions can help by creating attainable goals that emphasize 

skills commonly associated with health care delivery. Seen as a part of managing health care, providers 

can begin to view IPV as a problem that is solved over time rather than overnight and see themselves as 

one helper among many rather than a lone problem solver. A change in expectations can help providers to 

see the potential for success in their interactions with IPV patients. Providers often complain that it is 

difficult to help IPV victims because they view patients as, “unwilling to help themselves by taking action 

to leave the abusive partner.” Expecting to effectuate drastic life changes in patients’ lives in one 

treatment visit is unrealistic and typically results in providers and patients feeling disappointed and 

frustrated. 

A Shift in Perspective. One of the most common misconceptions about IPV by many providers is 

that the problem should and can be solved immediately. This is especially true in certain health care 

settings such as the emergency setting. The truth is that with the exception of a few cases, most victims 

need time to end the IPV in their lives. IPV relationships rarely are ended quickly and simply. For this 

reason, providers need to shift their goal away from fixing a patient’s problem or making the patient safe. 

Instead providers need to support a patient’s effort to seek help and at the same time address her health 

needs and record observations. These behaviors are well-within the provider’s expertise and help the 

patient in ways that can extend long past the visit. Documentation of a thorough assessment of injuries 

caused by IPV is a good example of important work that providers can do to assist patients. 

Providers understanding how they can play a role in the larger scheme of IPV service delivery 

enables them to contribute their expertise to patients’ problem solving, even if resolution of the problems 

occur sometime in the future. Providers may not see the beneficial outcomes of their work, but will know 

that by maintaining good treatment records, they afford patients what may be the only third party record of 

symptoms and injuries resulting from abuse. As such, these records can be vital in assisting patients to 

gain independence from their abusive partners. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 14 

Providers’ experiences with IPV will be more rewarding and less frustrating if realistic expectations 

are set, adequate resources to accomplish goals are available, and providers learn to coordinate their work 

with other services providers in and outside the hospital. 

Interdisciplinary and Institutional Collaboration. This evaluation project exists due to the 

working relationship built among research team members over several years. These relationships were 

built in the context of providing direct services to IPV victims in legal, shelter and health care settings. To 

improve services to clients, we forged new working relationships across institutions and disciplines. Such 

experiences taught us that sharing different areas of expertise, skills, access to resources and perspectives 

could only benefit each of our individual clients. Working cooperatively enabled us to spend more time 

with each client and turn fewer clients away. Each of us was released from the untenable task of being 

everything to every client and instead only responsible to deliver services within our skill and knowledge 

base. We provided services that were best suited to our professional role and referred clients to other 

services we knew well and to providers whom we trusted. Working across agencies and disciplines 

resulted in breaking the isolation that is so often associated with IPV service delivery in any professional 

setting. Surely, there are success stories of similar interdisciplinary working teams in other health care 

settings. However, this model has yet to be implemented completely enough to accurately assess its 

effectiveness. 

Interdisciplinary working may not guarantee success in every case but it improves the likelihood of 

accomplishing small successes that may pave the way to patients’ future safety. Supporting providers in 

each setting to implement a team-based approach and to build interdisciplinary working relationships 

increases the chances that change will occur on a level that will eventually change the culture of resistance 

that currently exists in many health care settings. Over time, implementing a consistent response to IPV 

will result in improved health care, increased satisfaction by providers who work with IPV victims and 

substantial economic savings to health care institutions. 

Future Research. Further study is needed to explore what strategies will increase institutional and 

administration’s investment and support of a consistent and effective IPV response in health care settings. 

Our project revealed that many providers have not been exposed to the wealth of knowledge and IPV 

resources developed over the past two decades. Even those providers who have been exposed to some 

information related to IPV have not had adequate incentive or support to incorporate this knowledge into 

their practice on a consistent basis. Lack of time was a serious concern for all participants in the study. 

Effective training and skills development to deliver health care that effectively responds to IPV takes time. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 15 

Additional research exploring different methods of disseminating information, incentive for acquiring 

increased knowledge, and identifying time efficient means of developing providers’ skills is much needed. 

A useful area of study would be a more in-depth examination of what changes would need to be made so 

that IPV education and clinical training were required course work in medical, nursing and EMT schools. 

A critical look at how implementation of an IPV protocol on an institution wide basis may effect or 

transform the culture of the setting as opposed to training specific providers or individual departments 

would also add to current knowledge. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 16 

 

Introduction 

Medical documentation regarding intimate partner violence, and testimony based on that 

documentation, are valuable tools for victims seeking legal relief from abuse. Inadequate documentation 

practices and under-utilization of medical records by attorneys currently hinder victims’ efforts to secure 

legal relief. In this project we developed, implemented and evaluated an intervention designed to improve 

the abuse documentation practices of health care providers, by encouraging them to apply diagnostic and 

documentation skills traditionally understood to fall within the medical realm of professional competence 

and responsibility. 

Health care professionals commonly encounter intimate partner violence (IPV) when caring for 

patients. Recent health care provider training has focused on screening, identification of IPV, and social 

service interventions for battered women. While providers are encouraged to identify and assist victims of 

IPV for services, focus groups and a review of training manuals and IPV protocols from around the United 

States reveal that providers rarely receive any direction regarding how and why to document IPV. While 

providers may be trained in screening and assessment, few who have received any training related to 

documentation of the assessment and treatment provided (Davidson, 2001). Providers have identified 

several issues that discourage them from documenting IPV in patient charts. These include: (a) not 

recognizing how helpful corroborative or direct documentary evidence of abuse may be to patients seeking 

protection, (b) misplaced fear that documentation can only increase provider’s risk of medical malpractice 

liability, (c) belief that documentation of IPV can only hurt the patient if anyone outside of the health care 

setting views the record, (d) belief that documentation will increase the likelihood of being called to testify 

in court, and (e) lack of specific training regarding time efficient documentation of injuries, patient 

statements and observations. 

Many patients who seek health care for injuries related to IPV eventually access legal means to 

achieve violence-free lives. Legal remedies include prosecuting abusers, obtaining abuse prevention 

orders, seeking custody of and visitation with children, applying for benefits and housing privileges, and 

securing immigration rights. Medical records that document abuse can make the difference between 

success and failure in obtaining any of these forms of relief. Currently, however, many attorneys do not 

utilize medical records in these contexts. Reasons for not using the records include (a) difficulty and 

expense in obtaining records, (b) illegibility, incompleteness or inaccuracy, of documentation and (c) the 

possibility that the information in records, due to these flaws, may be more harmful than helpful. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 17 

The current project builds upon the previous work of a unique medical-legal, researcher-practitioner 

collaboration. The prior project, hereinafter referred to as Legal Evidence Project 2002, explored the 

utility of abuse related medical records in legal proceedings, revealed the concerns and problems 

associated with documenting IPV in health care settings and made recommendations as to how providers 

should document IPV. Originally, the current project was designed to improve providers’ documentation 

skills in order to improve the quality and continuity of care and provide patients with useful corroborative 

evidence of the health impacts of abuse. As a means of achieving this goal, we intended to develop a 

training program focused primarily on documentation of IPV. We hoped that increased positive 

experiences with IPV patients would encourage providers to increase identification, continue to develop 

their assessment skills and provide patients with more information about the health impacts of IPV. 

However, once we began investigating the current practice in each of our study settings, we concluded that 

focusing on documentation without first addressing assessment and response to IPV would be impossible 

given the frequency and quality of response to IPV in the three settings. In order to accomplish our 

primary goal of developing an intervention to improve documentation we needed to perform two additional 

tasks. We needed to develop a response to IPV that addressed the needs of the providers in each setting. 

At the same time, we needed to explore what structural changes and administrative resources were needed 

to support implementation of such a response. Once these additional tasks were accomplished, the 

research team developed a training that presented a recommended response to IPV that emphasized 

documentation, employed a patient empowerment model and relied on an interdisciplinary team approach. 

The training was administered to pre-hospital providers (Emergency medical technicians and paramedics) 

and residents and nurses working in the emergency departments of two large urban hospitals. After 

training was complete, we reviewed the records of providers who had received the training and conducted 

focus groups with a small subgroup of providers trained at each site. 

Expanding our project objectives resulted in our learning a great deal about what is necessary to 

develop and implement an effective intervention and gain insight as to what change must occur in order to 

improve providers’ documentation of IPV. However, further study is needed to determine the extent to 

which this type of in-service intervention will improve providers’ ability and willingness to document. 

Lessons learned the current project reveal a number of areas in need of further inquiry. 

This report begins with a brief overview of related research and literature. What follows is a short 

description of the Legal Evidence Project 2002. Next, is the “Methodology Section” which describes 

curriculum development, training implementation, medical record review, and post-training focus group 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 18 

data. In the following section, the results of our efforts are described. The conclusion contains important 

lessons learned about developing and evaluating an IPV intervention in a health care setting as well as 

recommendations for health care administrators and policy makers, health care providers, staff and 

ancillary services. 

Literature Review 

Statement of the Problem 

In the past decade, the legal system has dramatically changed laws, procedures, and practices in an 

effort to provide protection to battered women and their children. The type of impartial, extrinsic evidence 

on which judges and juries normally rely is often lacking in cases of abuse between intimate partners. 

Medical records and health provider testimony, based on such records, constitute potentially invaluable 

sources of evidence. 

Increasingly, victims of violence are disclosing partner abuse to medical providers. Because medical 

records are "kept in the ordinary course of business," relate to diagnosis and treatment, contain factual 

information such as the physical or emotional condition of the victim, or the behavior or demeanor of the 

perpetrator, they may be admitted into evidence in court proceedings (Ferris, 1997). Moreover, fact finders 

often view disclosures made to providers in the context of treatment with less suspicion than a report 

lodged with law enforcement, particularly if the disclosure and corresponding documentation is prepared 

prior to the initiation of litigation. 

Unfortunately, recent studies -- including the Legal Evidence Project 2002 -- reveal that even in cases 

where victims have been treated for intentional assault or injury, medical records may be inadequate to 

corroborate the existence of abuse, and may provide far less documentary evidence than they could 

(Smock, 1997; Covington, 1995; Abbott, 1992; Sugg & Inui, 1992). At the same time, there is ample 

evidence that health care providers want to assist victims of domestic abuse. Protocols for universal 

screening for IPV abound, and many include elaborate guidelines for intervention (Enos & McGuigen, 

1998; COBTH, 1997; MMS, 1997; Schornstein, 1997; Smock, 1997; PFVAP, 1996;WSNHC, 1996; 

Warsaw, A.L., Ganley, et al., 1995, CDPH, 1994 AMA2

, 1992, AWAKE, 1992, CSN, 1992). 

Unfortunately, these protocols often require the health care provider to perform assessments and take 

action outside their core area of expertise. 

Most problematic, however, is that precise documentation of abuse in a patient's medical record -- a 

task that is squarely within the provider's core area of expertise -- has been given inadequate attention both 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 19 

in the majority of protocols and in the training programs that accompany their use. Only a fraction of 

protocols provide specific attention to documentation providing examples and sample forms (Smock, 1997; 

Warsaw, A.L., Ganley, et al., 1995, Chez, 1994). Tools such as body maps, prompts, checklists and 

consent to photograph forms could be useful aids in many settings but there has been no investigation of 

what kind of effort or resources are needed to incorporate these forms in the medical record keeping 

system of a particular institution or the logistics related to ensuring consistent and accurate completion of 

these forms by providers. 

Few resources incorporate a legal perspective of how records documenting abuse could be used to 

benefit or harm victims of IPV in legal, administrative and social service settings (Enos & McGuigen, 

1998; Schornstein, 1997). Training materials rarely discuss the potential legal liability associated with 

treating patients experiencing IPV or medical record management. 

In a series of focus groups with health care providers in Boston, Massachusetts, providers identified a 

need for specific instruction and direction in documentation. Moreover, providers had many concerns 

regarding confidentiality and liability, were fearful of being asked to testify, and expressed confusion over 

what type of medical documentation might inadvertently hurt a victim of IPV. A small percentage of 

providers likened documentation of patient reports of abusive incidents to evidence collection that is 

already performed by police. These same providers worried that making accusations of partner abuse 

against a non-patient puts the provider at risk of retaliation by that person. In a recent study exploring 

providers’ attitudes, providers reported concern about patient safety, patient privacy and patients’ fear of 

criminal justice involvement to be significant barriers to identifying and responding to IPV (Rodriguez, 

1999). 

The original design of the current project sought to develop and test an intervention specifically 

designed to improve providers’ documentation of IPV. The rationale for the design was based on the years 

of health care attention to IPV indicated in research literature, clinically based resources and the multitude 

of protocols and training manuals available nationwide. We also assumed that each institution’s 

compliance with the Joint Commission on Accreditation on Healthcare Organizations mandates (JCAHO, 

1992) would ensure that providers were familiar with and trained to some degree in an IPV protocol. We 

confirmed that recommended responses to IPV had been introduced in each institution and that training in 

IPV had been conducted annually or bi-annually in previous years. Review of research literature and 

training materials indicated three areas that were well addressed: (1) screening and identification (2) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 20 

assessment (medical/social history, patient’s description of events, degree of injuries, and patient safety); 

and (3) referring patients to IPV services. We intended to build on providers’ current knowledge to 

improve health care delivered to victims and increase the likelihood of records accurately depicting the 

health care interaction in a way that best protected the patient, provider and institution 

However, record review and focus groups conducted prior to our developing the training curriculum 

helped us to understand that our original expectations as to the standard of practice was misplaced and 

inaccurate. Analysis of provider records performed in each study setting revealed that providers’ were not 

identifying IPV with any consistency. Focus groups with providers confirmed that screening practices and 

response to IPV were inconsistent. Providers who did respond focused on referring patients to IPV 

services rather than assessing and treating the health impacts of IPV. Focus groups also revealed that with 

the exception of a few providers, those who had attended previous IPV trainings did not incorporate the 

content into their regular practice. Only some providers were aware of IPV protocols. While all were 

familiar with the philosophy and procedures related to screening tools most still exhibited concern as to the 

viability of successfully responding to IPV in medical settings given time limitations, the multitude of 

other responsibilities and provider skills. Further, few providers articulated any incentives within their 

institutions to acquiring these skills or developing a consistent practice of identifying and responding to 

IPV. We were also surprised to find that specific methods of documentation were not used systematically 

within each site. General guidelines exist but each provider documents in his or her own personalized way. 

From these findings we concluded that we would be unable to address documentation without first 

defining a successful interaction with patients in the context of an emergency setting. Identifying these 

previously unanticipated issues early on in the project convinced us to expand the project goals to include: 

exploring what, if any, institutional resources or administrative changes were necessary to change the way 

providers addressed IPV; developing time efficient strategies that emphasized healthcare specific tasks to 

be performed before referring patients to IPV services; and identifying incentives for providers to address 

IPV more regularly in their practice. Improving documentation remained the primary goal for our project 

but we determined there was no way to address it in isolation from these other topics. Given the expanded 

goals before us, we also knew that we would have narrow the focus of the training. Therefore, we 

ultimately decided to develop a training that focused on patients who presented with physical, emotional or 

psychological symptoms relating to IPV. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 21 

Background and Significance of the Research 

Prevalence of IPV

Despite improvements in legal relief and resources over the past two decades, the number of women 

and children who are battered every year remains staggeringly high. According to a recent study 

performed jointly by NIJ and the CDC, approximately 1.9 million women are physically assaulted annually 

in the U.S. (Tjaden & Thoennes, 1998). This study estimates that between 20 and 30% of women and 

7.5% of men in the U.S. have been physically and/or sexually abused by an intimate partner sometime in 

their adult lives. Heterosexual women are much more likely than heterosexual men to be victims of IPV 

(DOJ, 1998). While there has been minimal study of IPV in the lesbian, gay, bisexual, and transgender 

relationships, data available indicates rates similar to those in heterosexual adult and adolescent 

populations. Millions of children are exposed to IPV each year (Edelson, 1999). A healthcare based study 

conducted on a large sample of Kaiser Health Plan members in California confirmed that over 10% of 

members in the sample indicated exposure to IPV as a child and a personal history of child abuse (Felitti, 

et al., 1998). For over a decade research has indicated that children exposed to IPV are also at risk, 

physically, and emotionally (Wolak & Finkelhor, 1998; Campbell & Lewandowski, 1997; Stark & 

Flitcraft, 1988; Jaffe, 1988; Bowker, 1988). Estimates of non-sexual and sexual dating violence among 

adolescents (age 13-18) range from 25-60% (Cohall, et al 1999; Foshee, et. al, 1996). Studies also show 

abuse against women and teens during pregnancy and postpartum (Martin, et al 2001; Silverman, et al 

2001; Parker & McFarlane, 1993). While there has been less research done in this area, studies indicate 

that IPV is also prevalent among elderly Americans (NEAIS, 1999; Toshiho, 1999). 

Assistance and Protective Relief Related to IPV

The risks to abused parents (usually mothers) and children may be at their greatest when the abused 

parent takes concrete steps to end abuse (Mahoney, 1991. Dobash & Dobash, 1979). Inability to obtain 

financial support from the abusive partner, maintain employment, and access safe and affordable housing 

is a major cause of homelessness for battered women and their children (Zorza, 1991). Recognizing 

victims' need for assistance, state and federal legislators have responded through the enactment of abuse 

prevention order legislation and grants to victims of specialized status in the administration of welfare 

benefits, housing, and immigration & naturalization. (Chung & Orloff, 1998; Meier, 1997). 

Meeting survival needs during and immediately following separation is only one of many steps a 

survivor will take during the long journey toward safety and independence. For example, continued, 

unrestricted access to the children through shared custody or visitation may present the abusive partner 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 22 

with continued opportunities to abuse, confront or manipulate the victim. In this scenario, the children 

may be physically or sexually abused themselves, even if they have not been abused prior to the parental 

separation (Zorza, 1995). Many states are becoming increasingly aware of the impact of violence on 

children, and courts are beginning to recognize the need to address these issues in custody and visitation 

determinations (Quirion, 1998). 

While civil abuse orders and criminal prosecution can increase victim safety, there are many barriers 

preventing women from accessing and participating in these systems. A victim's willingness and ability to 

commit to these relief systems is almost always conditioned upon her access to the resources necessary to 

establish independence and restructure a life without reliance on the perpetrator. A woman who seeks 

immediate relief through an abuse prevention order or participation in a criminal proceeding must also 

consider how this will impact her ongoing ability to house, clothe, feed and emotionally care for herself 

and her children. Thus, a victim's ability to access safe housing, transitional assistance, health care, trauma 

counseling and immigration representation will often dictate whether she participates in a prosecution or 

seeks a restraining order. 

Unfortunately, even those victims who are successful in obtaining restraining orders or prosecuting 

their abusers are not assured safety. One retrospective study of adult women in Seattle, Washington found 

that permanent, but not temporary, protection orders are associated with a significant decrease in risk of 

police-reported violence of women by their male intimate partners (Holt, et al 2002). However, another 

study of homicides in Massachusetts indicates that these forms of relief do not always provide the lifesaving protection intended (Langford, 1999). Out of 194 individuals murdered in incidents related to 

intimate partner violence, 52% of perpetrators had a prior criminal history in Massachusetts, 24% had 

active restraining orders against them at the time of the homicide and at least 40% percent had previous 

restraining orders against them at some time. At least 81 children witnessed these homicides or the 

immediate aftermath. These figures underscore the importance of combining abuse prevention and 

criminal remedies with relief such as safe housing, employment or welfare, supplemented with child 

support and equitable property division, as well as custody and visitation arrangements that protect every 

family member and hold abusers accountable. 

Documentation of Medical Treatment Can Assist Victims to Obtain Relief 

Regardless of the type of relief sought, many IPV survivors will have contact with the legal system at 

some point. As abusive partners have become more familiar with legal systems, they learn ways to 

manipulate the systems originally designed to protect victims to initiate false actions in retaliation to their 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 23 

partners’ efforts to seek independence. Currently, medical documentation is an underutilized tool in legal 

settings (Belknap, 1999). However, medical records could provide a valuable source of information for 

attorneys representing victims in a variety of contexts (Aycock, et al 2000, Dalton, 1997, Cramer & Forte, 

1988). 

Accurate and comprehensive medical documentation of intimate partner abuse is a valuable 

evidentiary tool to corroborate or establish the occurrence of an incident of or pattern of abuse (Cramer, 

1998). Medical documentation and testimony relating to medical treatment and diagnosis is admissible in 

a variety of legal settings. Medical documentation provides unbiased, factual information written at the 

time of, or shortly after abusive events, often long before any legal proceedings occur. Additionally, 

information regarding the impact of the abuse, physically and emotionally, is included in the assessments 

made. In the best of records, photographs capture the moment in ways that no description can depict 

months later (Belknap, 1999; Cramer, 1998). Medical records can be admitted in legal proceedings to 

establish the requirements necessary to obtain a range of protective relief and defend against false 

allegations or retaliatory legal actions by an abusive partner. Clinically accurate and comprehensive 

records provide a useful tool to attorneys working within settings where the rules of evidence are applied. 

Records may also be useful to victims without legal representation in less formal contexts to achieve 

specialized status or exemptions in the areas of public housing, welfare, immigration status, landlord/tenant 

disputes, health and life insurance, victim's compensation and employment. 

Health Care Response to IPV

In Legal Evidence Project 2002, we learned that health care settings may be the first place where 

victims seek help when experiencing IPV. Our findings indicated that many women who receive treatment 

for abuse in emergency department settings have not accessed other IPV services for a variety of reasons 

including fear, distrust of systems, lack of access due to language or citizenship status, and isolation caused 

by abuse (Isaac & Enos, 2002). Medical systems, ranging from emergency medical services to extended 

outpatient and inpatient care, regularly provide services to a large number of women and children affected 

by domestic violence. Over one million women seek medical treatment for abuse-related injury each year 

(Stets & Straus, 1990). Data from several studies suggests that 22-35% of women presenting to 

emergency departments, for any health problem, are currently experiencing IPV and presenting with 

related symptoms. As many as 37% of patients seen in obstetrics departments are physically abused during 

pregnancy (Council on Scientific Affairs, 1992.) Up to 21% of women presenting to primary care 

practices have experienced IPV sometime in their lifetime (McCauley, 1995; Abbott, 1992). Of 218 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 24 

women presenting to a metropolitan emergency department for injuries sustained during abuse by a 

partner, 13% required major medical treatment and 28% required hospital admission. Physical and 

emotional abuse are also linked to a number of adverse physical effects including arthritis, chronic neck or 

back pain, migraine and other frequent headaches, stammering, vision difficulties, sexually transmitted 

diseases, chronic pelvic pain, stomach ulcers, spastic colon, frequent indigestion, diarrhea or constipation 

and exhaustion (Coker, et al 2000; Kernic & Wolf, 2000; McCauley, et al 1998; Campbell & 

Lewandowski, 1997, Drossman, 1995). Patients, identified as victims of abuse, may be assisted by health 

care providers who may refer them to the internal social service department, or to outside programs such as 

a battered women's hotline, local law enforcement offices, or a local court. 

Fortunately, IPV has been recognized as a significant public health issue for women. Health care 

professional organizations including the American Medical Association, American College of 

Obstetricians and Gynecologists, American College of Emergency Physicians, American Academy of 

Family Physicians, American Psychological Association, American Nurses Association, American 

Academy of Pediatrics, and the Institute of Medicine of have developed opinion papers, recommendations, 

policy statements and monographs about health care providers’ response to IPV in recognition of this as an 

important health issue (FVPF, 2002). Foundations, such as the Family Violence Fund in San Francisco, 

have played an important role in promoting routine screening and effective intervention through 

publications, national conferences and other educational programming. Regional medical associations 

have developed and disseminated protocols along with training materials. Some hospitals and health 

centers have developed and implemented their own protocols and training requirements. During the last 

decade significant research, policy making, intervention and outreach has been performed by hundreds of 

providers, public health policymakers and IPV advocates and counselors across the United States. 

However, despite these significant efforts made, research has yet to show that providers have incorporated 

identification and response to IPV into their everyday practice. 

Efforts to train medical providers to address IPV have produced modest results in 

screening/identification and little or no change at all in assessment, treatment and documentation 

(Rodriguez, 1999; Derk & Reese, 1998; Parsons, 1995; Freidman, 1992). Providers seem to be 

uncomfortable with the issue of IPV and have little confidence in their abilities to respond to IPV 

effectively (Isaac & Enos, 2001; Sugg & Inui, 1992). One study of 400 physicians in California found that 

a majority of the providers reported that they routinely screen injured patients, relay concerns for safety, 

make referrals to shelter, counseling or police, and record battering in patients chart (Rodriguez, et al 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 25 

1999). While these are encouraging findings, there was no description of how providers documented IPV, 

whether or not interventions were documented, and no description of how providers responded to the 

health care needs of injured patients. In this study, less than half of the providers reported lack of training, 

time or information as major barriers to physicians responding to IPV. In another study of health care 

providers’ knowledge, attitudes, beliefs and behaviors, there was improvement in knowledge of legal 

requirements after IPV training (Gadomski, 2001), but the practitioners involved in the training were not 

followed to see if there was a demonstrable change in objective outcomes such as documentation as a 

result of the intervention. 

While there has been some inquiry into the barriers providers encounter which deter them from 

identifying and intervening in IPV (Brown, 1993; Sugg & Inui, 1992), a closer examination of the specific 

concerns of providers, the reality of these concerns and strategies to alleviate concerns is warranted. 

Several studies show that many survivors are in favor of direct inquiry about IPV by health care providers 

so long as questions are asked in a compassionate and discreet manner, and referral services are made 

available to victims. One recent study revealed that 85% of IPV survivors who responded positively to 

IPV screens accepted the opportunity to speak with an advocate who could link them with community 

social service agencies (Krasnoff & Moscati, 2002). 

Clinically accurate and comprehensive record keeping maximize the quality of patient care. To date, 

there are no studies evaluating the extent to which proper medical record management improves patient 

care, however, it is reasonable to expect that the patient would benefit in a variety of ways. Thorough 

documentation increases the likelihood that providers will find the root cause of health problems sooner 

rather than later, thereby eliminating unnecessary diagnostic procedures and expensive testing. Identifying 

and addressing abuse is also likely to reduce the number of patient visits and prevent severe injuries or 

serious health conditions from occurring in the future. This will lead to more efficient use of limited 

resources and allow providers to have more time for each patient. However, an increase in documentation 

of IPV will occur only if issues related to patient privacy, safety, and providers’ comfort in responding to 

IPV are addressed. 

Precise medical documentation in the area of IPV could also lead to improved record management 

practices overall. These principles could easily be incorporated in every day practice, thereby lessening the 

risk of liability to providers and institutions. Additionally, thorough documentation of patients’ problems 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 26 

will increase the likelihood of continuity of care and safeguard against potential failure to diagnose or 

misdiagnosis. 

Prior Work 

Building a Practitioner-Researcher Partnership to Research Documentation of Domestic Violence 

in Health Care Settings 

Northeastern University has had a medical/legal research collaborative exploring issues related to 

domestic abuse prevention since 1992. Recognizing the importance of IPV related medical documentation 

and testimony in legal settings, we established a researcher-practitioner partnership to explore the potential 

utility of medical records in legal proceedings involving battered women. 

As an interdisciplinary researcher/practitioner project, there is both a medical and a legal background 

component of the research. From a medical perspective, the vast majority of health centers and hospitals in 

many states have developed and/or implemented comprehensive IPV protocols and trained their respective 

staffs accordingly. The goal of these protocols is ambitious--to identify all patients experiencing IPV and 

assist them in accessing abuse prevention services that help achieve safety. 

While universal screening and intervention is theoretically ideal, protocols and training interventions 

often fail in practical application because hospitals and providers lack the resources to assist victims, and 

service organizations are often overwhelmed (Mcleer & Anwar, 1989). Health care providers are often 

frustrated, and many abandon the protocol altogether. When the protocol is abandoned, battered women 

and their children are denied the unique skills of the health care provider-- diagnosis, medical treatment of 

the abuse and thorough documentation. Recent studies show that training that improves providers’ 

attitudes, screening practices and referral rates, have little impact on documentation practices (Houry, 

1999; Harwell, 1998; Kripke, 1998). 

Executive Summary of the Prior Research 

The Legal Evidence Project 2002 sought to describe, from a legal perspective, how domestic 

violence is being documented in abused women's medical charts. In total, 96 medical charts of 86 abused 

women covering 772 visits were reviewed. For 184 of these visits (24%), detailed information was 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 27 

abstracted from the medical record documentation because there was an indication of domestic violence, 

an injury of some type, or both. 

The findings reveal important shortcomings of current medical charts as legal evidence of domestic 

violence. 

Based on the work of this practitioner-researcher partnership and the review of abused women's 

medical charts, we concluded the following: 

• The legal and medical communities hold many misperceptions of one another's roles in 

responding to domestic violence. Many barriers to collaboration are based on these misperceptions and 

false assumptions. 

• The work of the interdisciplinary partnership demonstrates that a common meaningful goal, 

mutual respect for one another’s professional expertise, and willingness to view a problem from a new 

perspective, can provide the context for productive medical/legal collaborations on the issue of domestic 

violence. 

• Some legal advocates do not utilize medical records regularly in civil contexts or to their full 

potential in criminal contexts. Reasons for not using medical records include: difficulty and expense in 

obtaining records; illegibility, incompleteness or inaccuracy; the possibility that the information in them, 

due to these flaws, may be more harmful than helpful. 

• Many if not most health care providers are confused about whether, how and why to record 

information about domestic violence in medical charts. 

• In an effort to be "neutral" regarding abuse situations, some health care providers are using 

language that is likely to harm an abused woman's legal case and aid her abuser (in a legal context). 

• Though physicians' poor handwriting is often the subject of jokes, it can in fact prevent use of the 

medical chart in court. In this study, among medical visits that contained some indication of abuse or an 

injury, one-third of the notes from doctors or nurses contained vital information that was illegible. 

• With minor modifications to documentation practices, many more abused women's medical 

charts would contain the elements necessary to allow their statements about abuse to be introduced in court 

as "excited utterances." Such evidence can allow a prosecution to proceed even when the woman is 

unwilling to testify against her abuser in court due to fear or for other reasons. The element needed for 

excited utterance exceptions that was most frequently missing from medical records was a description of 

the patient's demeanor. 

• Many providers record significant details regarding injuries and health conditions in abused 

women’s charts. If these practices were consistent, and symbols and abbreviations were standardized, this 

type of documentation could act as effective corroborative evidence in court. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 28 

• Emergency medical services (EMS) personnel may be an underutilized source of legal 

documentation of domestic violence. It appears that EMS providers may already be recording patient 

statements; with additional training, the legal utility of this data could be greatly increased. This is 

especially true given the proximity of these providers (in time and space) to the actual violent events. 

• Though many, if not most, protocols on healthcare response to domestic violence call for 

documenting injuries on body maps, this study found such maps or any types of drawing of injuries present 

in only a handful of medical visits. 

• Photographs, the "sine qua non" of evidence regarding abuse-related injuries, were almost never 

present in the charts reviewed in this study. Only one of the 93 visits involving an injury contained a 

photograph. The medical records also omitted mention of photographs stored in other locations, e.g., with 

local police. 

• Although the partnership discussions and prior focus group research had identified inappropriate, 

derogatory statements about abused patients as one current problem with medical documentation, such 

comments were found in physician or nurses’ notes in only five instances, and in social work or psychiatry 

notes in four cases. 

This research also identified some relatively minor changes in documentation practices that would be 

likely to improve the usefulness of abused women's medical records in legal contexts. Such changes may 

help health care providers to "work smarter, not harder" on behalf of their abused patients. Some 

recommended changes for clinicians include the following: 

• Clinicians should, when at all feasible, take photographs of injuries that are known or 

suspected to have resulted from interpersonal violence. Optimally, there should be at least one photo each 

of the full body, the injury itself, and the patient’s face. 

• Clinicians should take care to write legible notes. Clinician training should emphasize that 

illegible notes may negatively impact health care and are likely to hinder a woman's ability to obtain legal 

remedies to address her abuse. The increased use of computerized systems is helpful in addressing this 

common problem. 

• Clinicians should use quotation marks or the phrases "patient states..." or "patient reports..." to 

indicate that the information being recorded is coming directly from the patient. 

• Clinicians should stay away from words that imply doubt about the patient's reliability ("patient 

claims...", "patient alleges..."). Alleges is a legal term. It implies the statement following it is unproven 

and may not to have occurred. Providers should instead use quotes around statements made by the patient. 

If the clinician's direct observations are in conflict with the patient's description of events, the clinician’s 

reasons for doubt should be stated explicitly. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 29 

• Clinicians should not use legal terms such as "alleged perpetrator," "assailant," "assault", etc. All 

legal terms are defined with great detail by federal or state statute and case law. Typically, such terms are 

used by lay persons to mean something more ambiguous or larger in scope. By using legal terms, 

providers may convey an unintended meaning. For example, assault is defined as an attempt to cause an 

unwanted touching, whether or not the touching actually occurred. Naming the person who has injured the 

patient as her “assailant” or “perpetrator” after the patient has identified the person who has hurt her as a 

husband, boyfriend, father of her child or by name, is likely to be interpreted in a legal setting as the 

provider’s doubting the patient’s credibility. These terms are used regularly by attorneys seeking to raise 

doubt as to who committed an act. 

• Optimally, providers should describe and name the person who hurt the patient in quotes exactly 

as the patient has identified him. This prevents the abuser from obscuring his responsibility by accusing 

the victim of having multiple partners. 

• Practitioners should avoid summarizing a patient’s report of abuse in conclusory terms such as 

“patient is a battered woman”, “assault and battery,” or “rape” because conclusions without sufficient 

accompanying factual information are inadmissible in court. Instead, providers should document the 

factual information reported by the patient that leads them to conclude abuse occurred. 

• Placing the term “domestic violence” or abbreviations such as “DV” in the diagnosis fields of 

medical records is of no benefit to the patient in legal contexts. This practice should be reconsidered 

unless there are other clear benefits with respect to medical treatment. 

• Clinicians should include words that describe a patient's demeanor, such as: crying, shaking, 

upset, calm, angry, agitated, happy. Clinicians should describe what they observe, even if they find the 

demeanor to be confusing given statements of abuse. 

• Clinicians should record the time of day in their record, and (ideally) some indication of how 

much time has passed since the incident (e.g., "patient states that early this morning her boyfriend, Robert 

Jones, hit her...") 

Though these changes would go a long way to improve medical documentation of abuse, the research 

findings also imply that changes will be needed at the institutional level if the use of medical records in 

domestic violence cases is to improve. Specifically, it appears that: 

• The importance of photographing traumatic injuries needs to be re-emphasized in training 

programs on medical response to domestic violence. Research should determine the most common barriers 

to taking photographs. Interventions that aim at increasing the frequency of taking photographs should be 

developed and evaluated. 

• Medical units that handle abuse cases routinely (e.g., emergency medicine, social work) should 

have cameras stored in a secure but easy to access location. Resources should be allocated to buy cameras 

and film, and to train providers in their use. Each institution’s policy on response to domestic violence 

should include details on where the camera can be found, how to photograph injuries, where to store 

photographs, and how to document the existence and location of these photographs in the medical record. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 30 

• Non-clinical health professionals (medical records managers, administrators, risk managers) 

should work with domestic violence legal and clinical experts to examine changes that might facilitate the 

accessibility of medical records for legal use without compromising patient confidentiality. 

• Training regarding current health care response to domestic violence should be provided to 

judges who hear domestic violence cases regularly. 

• Domestic violence training programs and materials for health care providers should clarify that a 

failure to document domestic violence completely when treating an abused patient does not constitute 

taking a "neutral" stance about the incident. It will almost always convey a legal advantage to the abuser. 

In medical terms, it constitutes poor preventive medicine. 

The summary final report from the Legal Evidence Project 2002 is contained in Appendix F. Nancy 

Isaac, Pualani Enos and Judy Linden have presented the study to professionals from medical, legal and 

social science disciplines. At each presentation, conference attendees from various disciplines showed 

great interest and concern related to documentation of IPV and the privacy, confidentiality and professional 

responsibility issues that documentation raises. Papers related to various aspects of the project are 

currently under development, including a paper that describes the creation and progress of the partnership 

and the vital role practitioners played in the study with suggestions for use of this model in future research. 

The full final report from this project and the NIJ published research in brief is available on the NIJ 

website. 

This prior work provided us with the foundation on which to build the current project. The findings 

from the Legal Evidence Project 2002 will be further described and compared to data collected in the 

current project. 

Building on the Findings of the Previous Research 

In the current project, we sought to develop, implement and evaluate a training intervention designed 

to help health care providers utilize the skills of careful diagnosis and documentation. Our aim is to 

encourage all providers to improve those services to battered women that fall clearly within a health care 

provider’s area of professional competence and responsibility. 

Medical Information as Legal Evidence

 Medical documentation of domestic violence has the potential to be an advocate's most 

helpful tool in representing a victim. At the most basic level, it corroborates that an incident resulting in 

some type of health condition or injury occurred as indicated by the victim or other incident reports. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 31 

Additionally, the clinician creating the documentation has a scientific background and is trained to make 

unbiased observations and conduct interviews solely for the purpose of responding to health care related 

issues. A provider's reliance on a patient's information to determine treatment demonstrates that the 

provider found the information to be credible. Likewise, when a health care provider takes actions such as 

helping a patient to seek shelter, police assistance or emergency court response, this demonstrates an 

objective third party's concern. 

 When a victim presents to a health care provider with injuries, accurate and specific details of 

injuries can be used to prove that a batterer acted abusively. Even more importantly, these details can be 

used without the testimony of the victim or other witnesses to the event. There are two ways medical 

records, including photos, may become part of a court case. If a victim is too intimidated or frightened to 

participate in a criminal prosecution, prosecutors can obtain the relevant medical records through court 

order. 

A court will almost always order institutions to release injury photographs because they are highly 

relevant and probative. Because there is an excellent chance that a judge/jury will be persuaded by such 

evidence, the abusive partner may be encouraged to agree to a guilty plea or settlement agreement 

(Belknap, 1999; Cramer & Forte,1998). In the case of criminal prosecution, a defendant may plead guilty 

and be placed on lengthy supervised probation (possibly including attendance and completion of a certified 

batterer intervention program), providing some relief to a victim. A recent study found that arrest and 

conviction (not necessarily incarceration) decreased recidivism, while arrest without conviction increased 

recidivism (Gross, 2000). 

The extent to which medical documentation can serve as a tool for victims in legal settings remains 

unknown because it has been used so rarely in legal settings (Belknap, 1999). When it is used, it is usually 

by prosecutors in felony cases or by attorneys in tort litigation -- in cases involving permanent physical 

injury or death (Dalton, 1997). These are typically the cases in which an attorney has the time and the 

resources to obtain, review, prepare and submit the victim's medical records for use at trial. Improving the 

content and format of medical records would assist these attorneys in presenting this crucial factual 

evidence to the court. 

However, records could provide a valuable source of information for attorneys representing victims 

in a variety of other contexts, including: contested custody and visitation cases, child protective services 

proceedings where the abused parent is charged with neglect, and criminal cases where a former victim, 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 32 

now defendant, seeks to rely on the defense of “self-defense” or establish that the instant allegations are 

merely the abuser’s retaliatory accusations. 

While clinically accurate and comprehensive records provide a useful tool to attorneys working 

within settings where the rules of evidence are applied, they could also prove useful to pro se litigants in a 

variety of the less formal legal contexts, where victims are often denied relief because of failure to present 

the existence of abuse. Thus, by presenting persuasive factual support that abuse in fact occurred, victims 

may qualify for specialized status or exemptions in the areas of public housing, welfare, immigration 

status, landlord/tenant disputes, health and life insurance, victim's compensation and employment. 

Photographs are incredibly persuasive because they help to make the results of a partner's abusive 

behavior real to the judge/jury (Belknap, 1999; Cramer & Forte, 1998). Legal proceedings that determine 

the type of relief necessary for protection often take place months or even years after the abusive incident. 

During this time, the victim may have sought support and safety, and may currently appear to be both 

physically and emotionally healthy. Judges/Jurors may observe the results of a victim's effective coping 

skills and conclude that the abuser did little harm. Photographs of damage done on a particular day are a 

real reminder of what an abuser is capable of, the most important consideration for a fact finder. 

Photography has been emphasized in most health care protocols on domestic violence (Enos & McGuigen, 

1998; COBTH, 1997; MMS, 1997; Schornstein, 1997; Smock, 1997; PDFVP, 1996; WSNHC, 1996; 

Warsaw,1995; CDPH, 1994; AMA, 1992). 

In most states there are few admissibility requirements for photographs. If a witness can verify that 

the photograph accurately reflects the way the images contained therein looked at a relevant time, then it is 

admissible. While it is helpful to have an indication of the date, time, and place the photograph was taken, 

it is not essential. Additionally, there are no chain-of-custody requirements (i.e., there is no need for 

written documentation of who has had the pictures). 

Even before undertaking the research component of this project, the legal practitioners strongly 

believed that photographs are not used as often as they could be. Practitioners who work regularly in 

health care settings shared common experiences of lack of access to cameras, inadequate film refills and 

little training among providers. While the Polaroid Corporation provides training for institutions that buy a 

number of their cameras, many budgets do not include resources for the purchase of cameras or film. 

In a number of states, medical documentation may act as a substitute for live testimony by the 

provider, thereby relieving providers from the time and stress of testifying in court. Even when providers 

are required to testify, the provider can refer to records to refresh his or her memory. Unlike oral 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 33 

testimony based only on memory of the event, legible and accurate documentation written at the time of 

the event is safe-guarded against manipulation and distortion on cross-examination. Likewise, 

photographs and body maps provide the information in black and white or in color. Even where 

documentation may be limited in its scope, it can provide the missing piece of corroborative evidence that 

brings the other evidence together in a way that makes sense. The use of evidence other than the victim's 

testimony also prevents the victim from bearing the sole burden of making a case against her abuser. 

Clear documentation of abuse in medical records not only assists the victim and her legal advocate, 

but may also ease the burden on medical providers. Thorough and compelling medical documentation of 

abuse often encourages an abuser to settle a civil case or plead guilty to a criminal action without the need 

for extensive pre-trial and trial appearances by physicians and other providers. Even when the health care 

provider must appear, good records provide accurate and complete information regarding specifics that no 

individual provider could reasonably remember. Careful documentation of IPV also prevents malpractice 

actions against health care providers and institutions for failure to diagnose or properly treat partner abuse.

Evidentiary Considerations 

After identifying the documentation needed to corroborate abusive incidents, the legal practitioners 

considered in-court presentation of the information contained therein. Before facts may be considered by a 

judge or jury, they must be offered and accepted into evidence by the presiding judge. Oral or written 

statements must comport with the applicable "rules of evidence" before a judge will allow the statements to 

be "admitted" into evidence. 

Evidentiary rules vary from state to state. Federal Rules of Evidence do exist but govern state 

proceedings only if adopted by the state. Presently, most states have adopted some version of the federal 

rules through statutes or case law. Statutes typically define the scope of each rule in detail. Case law 

defines the rules through a piecemeal interpretive process, as attorneys litigate ambiguous issues before the 

appellate courts. 

At the first working group meeting, legal practitioners noted the complexity and difficulty of 

identifying all the evidentiary pitfalls surrounding the use of information from medical records in legal 

contexts. Additionally, they felt strongly that the analysis of evidentiary issues should be limited to 

Massachusetts law for the following reasons: they practice in Massachusetts; the records would most likely 

be used in Massachusetts courts; and analysis of an additional state’s law would increase the information 

sought exponentially. Legal practitioners summarized a number of the evidentiary rules for the non-legal 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 34 

practitioners so that a joint decision about the scope of analysis could be made. After lengthy discussions 

regarding the number of factors to be considered, and recognition that there would be variability in each 

judge’s interpretation, the group unanimously decided to focus its attention on only a portion of 

Massachusetts’ evidentiary rules. The practitioners prioritized a handful of rules, weighing the predicted 

persuasiveness of information, the relative difficulty of meeting the rules’ requirements and the frequency 

with which providers identify and record such information. 

Using these criteria, we limited our analysis to three evidentiary topics: 

Hearsay Exceptions Related to Admissibility of Information in Medical Records 

♦ Information relating to diagnosis and treatment 

♦ Medical Records (portions related to diagnosis and treatment) 

♦ Excited Utterances 

♦ Prior Consistent Statements 

♦ Prior Inconsistent Statements 

Photographs and Body Maps 

♦ Photographs 

♦ Body Maps 

♦ Drawings 

Issues Relating to Privilege and Confidentiality 

♦ Types of information that have heightened privilege 

♦ Frequency of information in each type of provider record 

♦ Location of information in record (relevant when redaction is required) 

♦ Requirements for release of records 

The Hearsay Rule and Related Exceptions

All states have adopted the hearsay rule. The hearsay rule prohibits admitting into evidence any outof-court statement offered for the truth of the matter asserted -- even if testimony is provided by the 

speaker, writer or actor of the offered out-of-court statement. All states have a number of exceptions to 

this rule, allowing certain out-of-court statements to be considered by a judge or jury. Judges decide 

whether a statement falls within the hearsay rule and if so, whether there are any applicable exceptions. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 35 

Information Related to Diagnosis and Treatment & The Medical Record Exception

One exception to hearsay is “Information related to Diagnosis and Treatment.” This exception 

permits health care providers to testify to matters related to care and treatment of a patient. 

Another exception is the “Medical Record Exception”. A handful of states, including Massachusetts, 

Maryland, Michigan, Maine and Utah, allow written records to "speak" in the place of providers in order to 

save providers the time, inconvenience and stress of testifying in court. The "medical records" exception 

provides that any portions of a certified medical record that are "related to diagnosis and treatment" may be 

included in the evidentiary record without requiring that a physician testify to the contents. Thus, a 

provider who writes comprehensive, specific, legible notes may be spared the burden of testifying in court. 

A practical limitation of the medical record exception is that only the portions of the record that can 

be read and easily understood by lay persons will be admitted. Thus, only a provider who writes legible 

records, containing terms defined by a medical dictionary and symbols relied upon by a medical treatise, 

will be relieved of the duty of having to interpret the records in court. 

The primary consideration related to the admissibility of statements contained in medical records is 

whether such information is related to diagnosis and treatment. In 1995, the Washington Court of Appeals 

in State of Washington v. Sims, 890 P.2d 521, explicitly held that statements identifying a patient’s 

abusive partner and his abusive behavior are admissible pursuant to a hearsay exception for statements 

made for the purposes of medical diagnosis or treatment. The court found that the physician must know 

who the abuser is to render proper care. In Sims, the hospital had implemented a policy of routinely 

referring assault or domestic violence victims to the social work department or to counseling programs. In 

Sims, the provider documented that he referred the patient to the social work department and suggested 

ways to avoid threatening situations to the patient. Also, the provider admitted the patient for an additional 

day in order to further social work interaction. The court concluded that the provider’s awareness of the 

abuser’s identity and behavior was useful to the patient’s care. 

Sims is the first case to acknowledge domestic violence intervention and similar information as 

relevant to “diagnosis and treatment”. Massachusetts’ courts have yet to interpret the scope of the medical 

record exception as broadly; however they consistently look to medical practice to guide their 

understanding of what is related to “diagnosis and treatment.” Even if statements are determined to fall 

outside the medical record exception, they may satisfy the requirements of other exceptions, such as the 

excited utterance exception, the prior inconsistent statement exception or the prior consistent statement 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 36 

exception. Also, even if not admissible as evidence, the statement may be used simply to refresh a 

witness’s memory. 

Excited Utterances

Another exception to the rule against hearsay, which is particularly relevant to statements contained 

in medical records, is the "excited utterance" or "spontaneous exclamations" exception. Massachusetts 

Law allows such statements to be admitted if the, “utterance was spontaneous to a degree which reasonably 

negated premeditation or possible fabrication and if it tended to qualify, characterize, and explain the 

underlying event” (Commonwealth v. Crawford, 417 Mass. 358, 1994). While some states require a 

showing that the speaker of the statement is unavailable, Massachusetts does not. Statements made during 

or soon after a stimulating event are considered to be reliable under the theory that a person who is reeling 

with emotion and stress from a shocking event is less capable of fabricating a description of the event. The 

partnership members agreed that this exception was a priority for research given the likelihood that a 

battered woman being seen for abuse-related medical conditions may share statements about an abusive 

episode soon after the incident. 

Three factors are relevant in determining whether a statement meets the excited utterance exception: 

(1) an identifiable statement, (2) the duration of time between the incident and the statement being made, 

and (3) the patient's demeanor when the statement is made. In some states, these statements may be used 

even in cases where the victim's testimony in court contradicts the excited utterance. The court's reliance 

on such statements, as recorded by police or health care providers, acts to relieve victims of the 

responsibility of "prosecuting" the state's case. The admissibility of the statements allows a victim to 

support the prosecution of her abusive partner without requiring her to testify in person against her abusive 

partner. The risk to the victim of retaliatory acts against her and her children is thereby decreased. 

To accommodate the number of elements that need to be satisfied for the excited utterance exception, 

a specific "Statements" tool was developed (see appendix). As other portions of the DV tool were 

completed (such as the tools for Doctors and Nurses notes), each "statement" in the record was separately 

abstracted using the "Statements" tool. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 37 

Photographs and Body Maps

Photographs are highly persuasive. In most states, photographs are not subject to chain of custody 

restrictions. In Massachusetts, a photograph may be admitted based on witness testimony that the 

photograph is a fair and accurate depiction of the object it purports to represent. Training for providers is 

minimal. Once trained, providers can do an efficient intervention that requires relatively little effort and 

decision-making from a traumatized patient. As part of the medical record, photographs are privileged. 

Another benefit to taking photographs is that the provider can give a set of the photographs to the patient 

for her to use on her own behalf. 

 Body maps are described in most domestic violence intervention protocols. Generally, body 

maps are outlines of the front and back view of a human body, providing clinicians an opportunity to 

diagram a patient’s injuries rather than describing them in a narrative. Body maps vary in size and some 

include a legend of symbols to use when drawing. Body maps are intended to save providers time by 

allowing them to draw what they see. Even if a body diagram is not contained within the paper work 

provided to physicians, providers may draw their own picture of the injury with notations regarding color, 

size, texture etc. Detailed drawings, whether in the form of a body map or hand written, effectively 

portray specific characteristics about a patient’s injury that can later be used to corroborate abuse. 

Privilege and Confidentiality 

In all states, a patient’s medical records are protected from release to anyone other than the patient. 

In many states, including Massachusetts, certain types of information contained in the medical record, 

including information related to sexually transmitted disease, AIDS/HIV, substance abuse treatment and 

psychiatric treatment have special privilege. Additionally, any information shared with a therapist, social 

worker, or domestic violence advocate is specifically privileged. No similar federal protection exists. 

Evidentiary privileges represent the states’ attempt to balance a patient’s right to confidential health care 

against a defendant’s right to a fair trial which includes admission of all relevant evidence. 

Health care institutions are legally responsible for protecting patients’ privileged relationship with 

providers. As part of this responsibility, institutions may only release information in the medical record 

when a patient consents through written release or upon court order. Frequently, only parts of the record 

are authorized for release. Under these circumstances, the institution is responsible for redacting those 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 38 

portions of the records that have not been authorized for release. The resources required to perform such 

redaction are dependent on the quantity and location of such information. 

Attorneys may request medical records without providing the patient’s consent for release or court 

order, either by telephone communications with the treating provider or by sending a letter or subpoena to 

the medical records department within the institution. Occasionally, information confirming that a patient 

has been treated within a particular institution or related information is released by that institution before 

privilege requirements are met. Similarly, information with special protection, such as counseling records, 

may be released when consent or court order has only authorized that information related to health care 

treatment be released. Institutions that fail to protect patient privilege may be liable to the patient for any 

harm resulting in unauthorized release. 

Some of the most hotly contested evidentiary battles before the court occur in domestic violence 

cases involving medical documentation of abuse, where the abuser seeks to obtain specially privileged 

information in an attempt to discredit and humiliate the victim. In Massachusetts, as in many other states, 

the abuser’s attorney must submit a written request to the court, detailing a good faith, specific and 

reasonable basis that the privileged material contains exculpatory evidence. If the abuser can make this 

showing, the judge will review the record to determine whether it includes relevant material to be admitted 

into evidence. 

 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 39 

Developing, Implementing and Evaluating a Documentation Training 

Overview 

Our approach to developing the documentation training involved three areas of inquiry: 1) What has 

been done in other settings and how well have those efforts worked?; 2) What are the opinions, concerns 

and experiences of providers and survivors?; and 3) What is the state of current documentation practices? 

We approached these inquiries through three different methods. 

To investigate our first inquiry we performed a comprehensive review of the medical and social 

science literature. This included extensive research into the confidentiality, privilege and professional 

mandates for various providers and potential liability of noncompliance with such requirements. Next, we 

solicited unpublished protocols, training manuals, guidelines and recommendations from health care 

institutions, agencies and organizations around the United States. To complete our second area of inquiry, 

we conducted focus groups with providers, social workers, psychiatrists, and advocates from study sites. 

During the same time period, focus groups with victims of IPV who had received health care from area 

hospitals were conducted. We also conducted focus groups with personnel from the risk management, 

medical records, and legal departments at these sites. Additionally, we conducted a number of interviews 

with legal counsel and risk management workers from other institutions to better understand hospital 

administration’s view of its institution’s response to IPV and whether provider’s concerns are 

acknowledged, relieved or heightened by messages they receive from the administration. Conducting the 

last area of inquiry involved reviewing the records of providers at each of the three settings to ascertain 

their documentation of IPV within the last year. 

Based on the results from the literature review, focus groups, and record reviews, we set out to 

develop a curriculum that acknowledged providers’ strengths, addressed their concerns, and improved their 

confidence and ability to document identification of and their response to IPV. We created a limited 

intervention that would enable providers to respond to IPV effectively within the time frame and using 

skills with which they are most comfortable. This limited intervention is unique in that it is dependent 

upon a team approach, employs a patient empowering approach and is not dependent upon the patient 

disclosing abuse. Once a core curriculum was developed, it was tailored to address the particular training 

needs of the three different health care providers: pre-hospital personnel (primarily EMTs and paramedics), 

emergency nurses and emergency medicine residents. The trainings addressed not only the type of setting 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 40 

and role of the providers but also how that provider interacted with other providers. The trainings also 

incorporated particular logistical differences between the three sites. 

Our goal was to reach 70% of the staff at each of the three sites. Over a period of 16 months, project 

faculty presented the training to 78% of workers at the Pre-hospital site, 60% of all nursing staff at Site #1, 

42% of all nursing staff at Site #2, 59% of all residents at Site #1 and 57% of the residents at Site #2. 

To evaluate the effectiveness of training at each site, we performed a post-training record review 

following the procedures used to conduct the pre-training record review and compared the two sets of data. 

Additionally, post-intervention focus groups were conducted with a small number of the providers trained 

at each site. 

Curriculum Development 

Focus Groups with Survivors, Medical Providers and Hospital Administration 

From the beginning of the grant 2001 until July 2003, we conducted a number of focus groups with 

providers, patients, IPV advocates, social workers, and hospital administration. We conducted seven focus 

groups with survivors of abuse who had accessed medical care sometime during their abusive relationship. 

Groups were conducted at battered women’s shelters, women’s centers, or health care sites. Survivors 

remained anonymous through the study and all identifying information has been modified to protect their 

identities. We also conducted two focus groups with each of the provider groups at the three sites to learn 

more about providers’ experiences, skills, and concerns about responding to patients experiencing IPV. 

We also conducted four focus groups with legal, risk management and medical record departments at each 

of the sites. To supplement this data, we conducted 20 individual interviews with providers, advocates, 

social workers, and hospital administration from area hospitals and health centers. Data collected in these 

groups are summarized below. 

What is striking about this focus group and interview data (presented in the three charts below) is the 

significant lack of a shared perspective, or, sometimes, even awareness of another perspective, with one 

exception. The survivors appear to have a keen awareness of the constraints and limitations on providers, 

and basically want thoughtful, respectful, confidential medical treatment, acknowledgment of their 

situation, and referral information. They don’t expect or want the medical professionals to be their 

counselor or to “do it all.” To be fair, many providers would like to help IPV survivors, are empathic to 

their plight, and do the best they can, but they feel hampered by time constraints and lack of expertise and 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 41 

knowledge about resources. In addition, providers have been trained to be problem solvers, and the 

complexity of IPV is not amenable to action-oriented problem solving in one, or even many visits. This 

clearly makes many providers feel overwhelmed—as if they weren’t doing, or can’t do their job. If they 

understood the abused woman’s perspective presented above, and had an awareness of the complexity of 

the process of change, they might feel more comfortable simply doing their job—asking about IPV, 

documenting it in the chart, validating the abused woman’s reality, and having available referral sources. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 42 

Comparing Perspectives (Pre-Training) on

Helpful Medical Interventions for Patients Experiencing IPV

Survivors Providers 

Treating the patient with care and respect 

• “The nurse treated me like she really felt badly about what 

happened to me. I don’t know that it was anything she said in 

particular but how she talked to me and how she listened.” 

• “I really appreciated how my doctor believed what happened to 

me and didn’t ask me what I did to make my husband disrespect 

me.” 

• “I was shocked when the doctor actually believed me about the 

abuse.” 

• “The only reason I ever got help and moved to a shelter is 

because of the nurse I saw after being raped and beaten. She 

made me believe that I didn’t deserve this, no one does. After I 

left that appointment I kept thinking about things she said about 

how things could be different.” 

• “Talking to the doctor made me realize what happened to me 

wasn’t right and there was no excuse for it. He made me realize 

I had rights.” 

• “The nurse told me what was going to happen, how bad the 

injuries were, what pain to expect and how long they would take 

to heal. Even though I was addicted to drugs at the time, she 

treated me like a normal person.” 

Little mention of building trust with patients. 

• focus on problem solving 

• concerned with significant action steps 

• persuading the patient to 

o leave the abusive partner, 

o going into shelter or 

o calling the police 

Exceptions 

• “When patients come in with injuries that seem to 

come from IPV, I want to ask them about abuse 

immediately, but first I address their medical needs 

and try to develop some kind of relationship with 

the patient as I treat her medically. Then, at the end 

of the interview I’ll ask how things are at home, is 

there stress at home and if she is ever hurt at home.” 

• “The best time to ask patients if they are afraid of 

their partner or someone at home is at night when 

the department is slow and you have more time to 

talk with them.” 

Sharing resource information 

• “There are some times when you can’t tell anyone what is going 

on. You are too frightened or traumatized by what happened and 

you don’t know who to trust. I don’t see why they have to press 

you to tell them. They obviously know what happened. Why 

can’t they just give you numbers to call or treat your injuries and 

let it go. Instead it’s like they want to punish you for not telling 

them.” 

Most providers know little about resources for 

IPV 

• “I don’t know where to tell victims to go and even if I 

did I wouldn’t have the time to do so. I usually refer 

them to a psychiatric nurse who can help them call the 

police or whatever they need.” 

• “Sometimes we can get the police to come in and 

interview the patient, but usually she had to go to the 

station.” 

• “It probably wouldn’t take too much time to give 

patients numbers of resources if we had something to 

hand out.” 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 43 

Comparing Perspectives (Pre-Training) on

Helpful Medical Interventions for Patients Experiencing IPV (cont’d)

Survivors Providers 

Maintaining patient’s privacy and confidentiality 

• “It is so unsafe for victims to go any where for help. It’s really 

important that health settings know how to protect your privacy 

and medical information.” 

• “Information relating to abuse should be given extra protection 

so victims know it’s safe to go to hospitals for help.” 

Mentioned No Concerns About Maintaining 

Patient Privacy And Confidentiality. 

Recognizing the risk to patients who seek help 

• “The biggest danger to you is telling someone what’s going on.” 

• “You have to know you can trust someone before you can ask 

them for help.” 

• “Due to isolation, EVERY person you reach out to is a big deal.” 

Some recognize the risk of victims’ help-seeking 

while others do not. 

• “I don’t know that these victims realize how unsafe they 

are. It’s really sad.” 

• “At least when they are in the ED, I feel like we can 

keep them safe.” 

The medical record may be the only record of the 

pattern of abuse 

• “When I finally had the resources to divorce my husband, he 

told the family court that I was a drug addict so that he could get 

full custody of our child and prevent me from having any 

visitation. Thankfully my doctor had documented my husband’s 

abuse against me for several years prior, so the records could 

show that my weight loss and other facts that my husband 

claimed were symptoms of drug addiction were actually 

responses to abuse. He also documented how my husband was 

never present for prenatal visits, the birth of our son or any 

follow-up pediatric visits for my son.” 

• “I would have lost my children to child protective services if my 

doctor had not documented injuries related to abuse by my 

husband.” 

• “I don’t know how I would use the records, because I never had 

to. But I guess it’s good to have some record of what happened, 

just in case something happens to you.” 

• “Comprehensive documentation is very helpful in that it saves 

you from having to tell the same story to different people over 

and over again.” 

• “Providers can be on the same page if they all update the file.” 

• “Records that are incomplete or negative toward the victim can 

be more harm than help because batterer’s attorneys can use the 

records to retaliate or discredit the victim.” 

• “I don’t care if my abuser’s name is in the record. I want 

everyone to know what he did to me. Maybe it will put him in 

jail.” 

• “Records should include physical injuries but also symptoms 

related to verbal and emotional abuse.” 

The less documentation the better 

• especially with social problems like IPV 

o “I’ve just been told to be very vague about what 

we ask and how the patient answers. Many 

times I won’t include anything about IPV for 

the patient’s protection.” 

o “I’m afraid if I document in too detailed a way, 

I will hurt the patient because someone can use 

that information against her later.” 

o “We share the most important information -- 

most personal information about IPV-- we 

share through oral communications rather than 

writing it down.” 

• patients should be able to choose whether IPV 

is written in their medical records. 

• only a few write down statements in quotes and 

include facts about physical and emotional 

abuse. 

o “Sometimes there is so much to document it is 

hard to get it all down. But when I have time I 

try to get down as much about what happened 

as possible.” 

• Most did not mention taking photographs as a 

part of documentation. 

o “We don’t take photos. I think the social 

workers or police do it.” 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 44 

In addition to the points discussed above, the second of the charts comparing perspectives on harmful 

medical interventions highlights two important issues: pressuring patients to talk about or do something 

about the abuse, and concerns about privacy. With regard to privacy concerns, it was not even mentioned 

by the providers, while it is clearly a big concern to abused women. 

As mentioned earlier, a successful outcome in medicine is often defined by getting the patient to do 

something that the provider thinks s/he should do. Battered women spend of great deal of time being told 

what to do by their abuser. It is not helpful for medical providers to continue treating them as if they do 

not know what is in their best interest. Davies, et al. (1998) in Safety Planning with Battered Women, have 

put forward a cogent argument on woman-defined advocacy and safety planning, that focuses on helping 

the abused woman do what she wants to do. This position is made explicit by one of the survivors, 

“Doctors and nurses shouldn’t tell victims that they need to get safe, they already know that. What victims 

need is someone to help them to figure out HOW to get safe.” Keeping the survivor from leaving, in a 

misguided attempt to keep her safe, is another example of seeing things only from the providers’ 

perspective and not understanding the importance of the abused woman defining her own needs. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 45 

Comparing Perspectives (Pre-Training) on

Harmful Medical Interventions for Patients Experiencing IPV

Survivors Providers 

Providers trying to do more than they have time for 

• “Some doctors try to do everything, be your counselor, safety plan 

and all of that but I know they don’t have time for that. The best 

thing my doctor ever did was treat my medical problems and call in 

an advocate who could work with me not only at the hospital but 

help me to get into housing, move me and my kids and explain to 

me how to get what I needed from the courts.” 

• “The doctors were so concerned about how I felt and what I was 

going to do about calling the police, he never fully examined me, 

wrote down my injuries, or took pictures. He ended up 

misdiagnosing me with muscle ache instead of the real problem 

which was nerve damage.”

Most try to do as much as they can with the 

time they have. 

• “I really don’t know what to do, but when I have time 

I try to do what I can.” 

• “If I can I ask about whether a patient feels safe at 

home and then talk to her about who she can talk to 

for help.” 

A few think they have no time to deal with IPV 

and that it is not a part of their role/expertise. 

• “So many of my previous experiences with patients 

who are abused were so frustrating. They were time 

consuming and seemingly ineffective. If you are 

limited time wise, I’d just as soon spend my time 

doing something I know will be useful.” 

Provider discomfort with IPV 

• “It is obvious when a nurse or doctor is uncomfortable with abuse – 

they ask you but its clear they don’t want an honest answer because 

then they have to deal with it.” 

• “Medical people shouldn’t ask the screening questions if they don’t 

want an answer. The worst thing is when they ask you, you say 

‘yes’ you are in danger from abuse by a partner, and then they do 

nothing. Why bother asking if they aren’t going to do something 

about it.” 

Fear of being intrusive and feeling 

incompetent 

• “Most patients are uncomfortable telling us about 

IPV, why should they tell us, they don’t even know 

us.” 

• “Feelings of incompetence relating to “making people 

safe”; counseling skills, knowledge of resources and 

protection systems”

Pressuring patients to talk about abuse 

• “There are some times when you can’t tell anyone what is going on. 

You are too frightened or traumatized by what happened and you 

don’t know who to trust. I don’t see why they have to press you to 

tell them. They obviously know what happened. Why can’t they 

just give you numbers to call or treat your injuries and let it go. 

Instead it’s like they want to punish you for not telling them.” 

• “It’s obvious by what is going on in the emergency department that 

the doctors and nurses don’t have time to listen to all your problems 

and help you like a counselor would. So what is the point in telling 

them the whole drawn out story.” 

• “Of course I wanted to tell someone what was happening. When he 

asked if my boyfriend hurt me, I wanted to scream, “YES! How 

else do you thing this happened.” But I was too afraid of what 

might happen if my boyfriend found out I told someone. I tried to 

give a glance or look but they never figured it out.” 

• “Instead of asking so many questions they should tell ... you of 

choices.” 

Many described frustration dealing with IPV 

• they feel patients lie about the abuse or 

• they do not want to do what is necessary to 

end abuse in their lives. 

“There are times when you know abuse is happening but 

the patient just denies it. What can we do if the patient 

doesn’t tell us about the abuse.” 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 46 

Comparing Perspectives (Pre-Training) on

Harmful Medical Interventions for Patients Experiencing IPV (cont’d)

Survivors Providers 

Inadvertently creating unsafe situation for patients 

• “Medical Staff has to understand that trying to get you to talk 

to them when your abusive boyfriend is waiting outside in 

the waiting room is not safe. It’s just not a safe time to talk. 

What would be best is if they arranged a time for you call or 

come back to talk.” 

• “When the staff won’t let you leave or threatens to call child 

protective services on you if you don’t leave your partner, 

they are not helping you to get safe. Many victims go to the 

ED in secret, without their partner knowing. When someone 

from the ED calls looking for the patient, the victim has to 

make up lies as to why they are calling. This can prevent her 

from ever going back to that institution.” 

Most stated that they worried if they don’t 

separate the patient from her abusive partner and 

prevent her from going home, she will be at risk. 

• “I tell patients that I’m most worried about, ‘I’m not going 

to let you go home if you are going back to him. You need 

to find a way to ensure me that you’ll be safe when you 

leave here.’ It’s my job to make sure the patient is safe 

when she or he leaves the department.” 

 

Pressuring patients to: call the police, go to shelter, 

get a restraining order, and/or leave the abusive 

partner 

• “Doctors and nurses shouldn’t tell victims that they need to 

get safe, they already know that. What victims need is 

someone to help them to figure out HOW to get safe.” 

• “They don’t have as many resources for gay, lesbian, 

bisexual and transgender folks like they do for heterosexuals. 

You never know how the police or people at the court will 

treat you. It might be more dangerous to you than what is 

happening with your partner.” 

• “The medical staff was so helpful but then they wanted me to 

call the police. I told them I was too scared. They didn’t 

want to help me after that.” 

“Success stories” are when patients leave their 

partner, call the police, or go to a shelter. 

Providers enjoyed spending their time on these cases 

but they were the exception to what usually happens. 

• “IPV is so frustrating because it just keeps happening and 

gets worse over time, and the patients just keep going back. 

How are we supposed to help if they don’t want help?” 

Failing to protect patient privacy 

• “Sitting out in the waiting room or hallway while you are 

waiting for treatment is so humiliating. They should have a 

special room for victims that is private.” 

• “The way they write your name, medical condition and ‘DV’ 

on board in the ED for everyone to see is a violation of 

privacy. There is no reason why everyone needs to have all 

that information.” 

• “The medical files are kept in places that anyone could grab 

them and read through them.” 

• “An abusive partner can easily get information from your 

medical record by saying he is the husband and concerned 

about the patient or by having a woman call and pretend she 

is the patient.” 

• “I don’t mind telling my doctor about the abuse but I don’t 

want to him to tell everyone he works with or write about me 

in some article.” 

Providers did not raise this as a concern. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 47 

This last chart compares the perspectives of the different stakeholders who have an interest in what 

goes on in the emergency department with regard to IPV, and goes beyond just the survivors and providers. 

Legal counsel, risk management, and medical records present their views with regard to hospital 

administration and liability issues. Again, there is a significant lack of awareness of each other’s 

perspectives, except for the survivors who are very aware of the providers’ need for more resources. It may 

simply be that they are in a position to observe the need for resources, as it so directly affects their own 

needs. There is one other example of awareness—this time on the part of legal counsel/risk management. 

They seem to be aware of providers’ tendencies to want to solve the IPV problem, as one says, “Providers 

are not required to solve the problem of IPV but are required to recognize symptoms of IPV, and impacts on 

health, and address those impacts.” However, legal counsel/risk management made no mention of resources 

for the providers to deal with IPV, no mention of the liability issues related to documentation, and while they 

had a number of cogent comments on how to document, it was clear from the provider statements that these 

had not been passed on to the people who needed them. Legal counsel/risk management had another astute 

observation about liability--“The best way to avoid litigation is to have a positive relationship with patients 

which includes honesty, trust and open communication.” It is not clear if this advice was delivered to the 

providers. 

 The medical records comments appear to exist in a vacuum with little demonstrated awareness of the 

complexity for the institution as a whole of the problem that is being documented in the record. It is ironic 

that the survivor/patient who is having trouble getting her IPV needs met in the emergency department is 

the one stakeholder who doesn’t mention liability issues. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 

Comparing Perspectives (Pre-Training) on

Providers’ Concerns Relating to Hospital Administration and Liability

Providers Legal Counsel & Risk 

Management

Medical Records Sur

Lack of resources is a big problem for us • “Often, we have to rely on family 

members or staff to interpret because there are no interpreters available for that particular language. This can create real problems if the abuser is the interpreter.” 

• “The DV services here are very limited. 

The advocates are only available part of the day.” 

• “What the patients need from us requires 

more than the 5 minutes we have to give. It’s very difficult to spend lots of time with one patient when the other patients also need your attention.” 

• “We (residents) don’t have time to get 

involved in IPV. Nurses do it.” 

No mention of resources to deal with IPV 

Providers are required to document comprehensively in medical records. 

Providers need more r

• “There is no way doctor

we’re going through and problems of all the patieadvocate or social worke

• “Many times it seems lik

dealing with many patien

• “When some doctors ask 

you can tell they are pray

• “My experience was gre

knew what was going onwhat happened, rather thsame story.”

IPV problems cannot be solved in the ED • “Its very hard to ask about a problem 

when half the time you don’t have any solutions for the patient.” 

• “We are in the business of saving lives, 

not changing lives.” 

• “I find ways to do what I can, with the 

time I have. I might not change someone’s life but at least I’m doing something.” 

Required to recognize, not solve IPV • “Providers are not 

required to solve the problem of IPV but are required to recognize symptoms of IPV and impacts on health and address those impacts.” 

Can’t change life in on• “No patient’s life can be 

This document is a research report submitted to the U.S. Department of Justice. This report has not been published by the Department. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 

Comparing Perspectives (Pre-Training) on

Providers’ Concerns Relating to Hospital Administration and Liability (cont’d)

Providers Legal Counsel & Risk Management Medical Records 

Vague understanding of patient privacy and confidentiality rights • “I know we can’t release records but 

if a family member wants to know what is happening to a patient, of course we want to let them know.” 

Confidentiality governed by HIPPA (April 2003) • Staff access is on a need to know basis; 

Information is shared among people with the same type of privilege 

• Heightened privilege—DV advocates, rape 

counselors, some social workers, psychiatrists, psychologists 

• Medical information is only released 

through consent of patient, when statute mandates, or court order. Institution should assert the privilege upon subpeona 

All Medical Record Departments abide by nationally promulgated procedures to handle records. • “We have strict polices and 

adhere to practices of a national organization to manage our records and protect [them] from inappropriate release.” 

Proneepat• • • 

Documentation training and supervision is sparse. • “I’ve just been told to be very vague 

about what we ask and how the patient answers. Many times I won’t include anything about IPV for the patient’s protection.” 

• “I’m afraid if I document in too 

detailed a way, I will hurt the patient because someone can use that information against her later.” 

• “No one really tells you how to 

document. It is very intuitive. It depends on how much time you have.” 

• “There is no specific place on the 

form to write everything the patient tells you. A checklist of some sort might be helpful to cut down on writing time.” 

Documentation should be comprehensive, but not extensive • “It’s best to document facts and 

observations only. The less extra information or commentary by physicians the better.” 

• “Providers should note any inconsistencies 

between IPV symptoms and patient’s reports.” 

• “Providers should document that they 

identified IPV, offered resources and that the patient acknowledged resources. They don’t have to note how the patient used the resources.” 

• “Providers should not editorialize.” • “The fewer details in the record the better, 

given how often providers are inconsistent in their notes. Documentation in broad terms reduces likelihood of inconsistencies.” 

IPV should be documented within the medical chart, if it is related to visit. • “IPV should be documented like 

any other clinically diagnosed problem.” “Once something is written in a record it is permanent so providers should show care in what they write. While some information may be redacted for certain purposes, nothing may be altered.” 

• “The record has no place to store 

photographs or body maps.” 

IPV in msurthaimp

This document is a research report submitted to the U.S. Department of Justice. This report has not been published by the Department. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 

Comparing Perspectives (Pre-Training) on

Providers’ Concerns Relating to Hospital Administration and Liability (cont’d)

Providers Legal Counsel & Risk Management Medical Records 

Lack of understanding about liability risks & documentation • “I have only been told, ‘don’t create 

a liability.’ I assume that means less is more, so I write as little as possible.” 

• “I really don’t know about liability. 

No one has ever trained us about it.” 

• “We (residents) don’t know much 

about it but we’re covered by the hospital.” 

• “We (nurses) have to buy our own 

malpractice insurance and it is expensive. If something happens, the blame is going to be directed at us.” 

Did not mention liability with regard to documentation • “The best way to avoid litigation is to have a 

positive relationship with patients which includes honesty, trust and open communication.” 

• “We help to prevent adverse events and help 

providers to manage events should a mistake happen.” 

• “Even unsuccessful litigation can create months 

of stress and humiliation for providers.” 

• “The legal department consults to providers, 

advises them in how to respond to complaints or problems and helps them prepare for court appearances. If a provider is sued, an outside firm represents them.” 

Don’t release records without consent & Difficulty getting charts back from providers • “If a patient doesn’t consent to 

all information, including sensitive information with heightened privilege, we won’t release the records.” 

• “We have a lot of difficultly 

getting files back from providers.” 

This document is a research report submitted to the U.S. Department of Justice. This report has not been published by the Department. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 51 

In addition to the comments presented in the charts, survivors had some specific recommendations 

for providers who want to help them. 

Patient Recommendations for Providers: 

 Hospital feels like “home” to you but it is scary for us. 

o Be kind and caring. 

o Don’t use humor to release stress in front of patients 

o Don’t joke about patient concerns in front of them 

 It’s important to take battered women’s health seriously. Providers need to take physical 

injuries seriously, not just focus on emotional symptoms of a victim. 

 How to talk to us 

o Even if people don’t say “yes” to questions about whether they are being abused, you 

should still give them access to information and resources about how to get help. 

o Don’t give advice – talk about options, provide information that gives a different 

perspective than what your partner is telling you. 

o When hearing about emotional problems, don’t put us on tranquilizers. Just ask 

what’s going on and what might help us to get through it 

 Documentation 

o Documentation is beside the point. A trusting relationship is most important. 

o Write a referral was given but don’t say to where or what kind 

 Confidentiality 

o Doctors [providers] should be trained on confidentiality. 

o Real sanctions should be in place to enforce confidentiality. 

 Dealing with batterers 

o Batterers are very manipulative even though they seem caring and concerned. Don’t 

let them fool you. 

o Don’t ask me if I want my husband to leave when is standing right beside me, there’s 

no way I can say ‘yes’ in front of him. Tell him you need to meet with me alone with 

so it looks like its normal procedure, not that I want my husband to leave. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 52

Current Literature Review 

-- Existing Protocols Attention to Documentation -- 

In order to assess how often documentation was addressed in training materials and protocols 

designed to assist providers in responding to IPV, we reviewed over 60 protocols from Massachusetts and 

other states nationwide. Many of the protocols paid only brief attention to documentation directing 

providers to document “carefully” or “well.” None of the protocols addressed the provider concerns 

relating to documentation that were raised in focus groups conducted for this current or previous project. 

We did find some helpful examples and examples in a few of the training manuals. These protocols are 

listed in the references list of this report. 

-- Legal liability related to IPV intervention -- 

We performed extensive local and national legal research to ascertain what, if any, liability is 

associated with medical providers responding to IPV. In our previous project, some of the providers 

articulated concern that they could be held liable for documenting abuse in a patient’s medical record, if 

the partner accused of committing the abuse, could later prove that such abusive behavior did not occur. In 

the current project, none of the providers identified liability relating to defamation or libel as a concern. 

However, many were concerned that but an ineffective response to IPV or allowing the patient to leave the 

medical site without ensuring her safety could make them vulnerable to liability. We reviewed legal, 

medical, social science and public health publications and found no indication that such liability exists. 

While the lack of existing case law or statutory law directly addressing this issue does not preclude the 

possibility of such liability, it does demonstrate that it should not be a pressing concern for providers at this 

time. 

While it was not identified as a concern by any of the providers, our research indicated that liability is 

more likely to arise from improper release of confidential medical information. A patient’s right to privacy 

in health care settings is explicitly set forth in the Health Insurance Portability and Accountability Act of 

1996 (hereinafter HIPPA). One of the primary intents of this law is to reduce the cost of health care by 

creating a more efficient transmission of payment through electronic transmission. The Department of 

Health and Human Services (hereinafter DHHS) has been promulgated regulations to ensure the patient’s 

privacy rights would be protected under this law. Since April 2003, hospitals, health care providers, health 

plans, and health insurers and health care clearinghouses are all required to comply with measures set forth 

in the finalized DHHS regulations, 45 C.F.R. section 160.101-164.534. These regulations establish federal 

privacy rights for patients and simultaneously create new civil and criminal liability for health care 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 53

providers. These regulations firm up any common law privacy rights held by patients prior to the April 

2003 and create incentive for medical care institutions to take great care in releasing medical records and 

for training providers of the risks related to sharing patient information through in-person, phone or fax 

communications. Specific provisions for IPV also create expanded protection for medical records of IPV 

survivors. The penalties for non-compliance with these regulations are fines up to $25,000 per person per 

year, punitive fines and the possibility of incarceration. 

We also investigated is whether adopting a protocol within a healthcare setting would somehow 

increase the risk of medical malpractice to providers who did not adhere to protocol guidelines. We were 

unable to identify any jurisdictions where any IPV protocol has become so part of practice as to be 

considered, “a standard of care that would be exhibited by the care and skill of an average qualified 

practitioner.” While some states evaluate a medical providers behavior against others within their locality, 

Massachusetts compares providers to others within their specified area of medical specialty (Jane Doe, 

Inc., 2003). While there are no cases in Massachusetts that address IPV specifically, there is one case that 

indicates that juries could reasonably find a provider liable for not have the necessary protocol in place 

(Derry v. Podkin, MD, 1999). Given the requirements of JCOAH and several other professional 

organizations, and the availability of protocols and training materials from national, state and local 

organizations, it is foreseeable that a jury would find a provider or institution liable for failing to 

implement appropriate protocols. 

While medical providers in seven states (California, Colorado, Kentucky, Mississippi, Ohio, Rhode 

Island, and Texas) are mandated to reporting of IPV to law enforcement (Linden, 2002), Massachusetts 

medical providers are not so required. However, providers in Massachusetts are required to report gun 

shot wounds, rape and knife wounds, so if these injuries occur in the context of IPV, they are required to 

report them although these reports are not necessarily made to law enforcement. Since mandatory 

reporting of IPV was not a concern for providers at our three sites, we did no more than assure them that 

they were not required to report cases of IPV to the police. 

Pre-Training Medical Record Review at the Three Sites 

Our original research design indicated that we would rely on the record review conducted in Legal 

Evidence Project 2002 to evaluate the efficacy of the documentation training. However, due to funding 

delays and other circumstances, the project was not initiated until two years after the first project’s 

completion. Accordingly, we felt it necessary to do a current review of provider records at each site. We 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 54

decided to use this opportunity to confirm findings from the first project and ascertain specific problems in 

providers’ current note taking to inform training curriculum development. 

We used a modified version of the abstraction tool used in our previous project, Legal Evidence 

Project 2002, to review the records. We used a modified Delphi method to create tool in the first project. 

The interdisciplinary team of lawyers, doctors, nurses and social workers were presented with variables of 

interest selected from well-known health care intervention protocols, a summary of relevant legal 

background and evidentiary rules, and data from focus groups conducted with providers. The group met 

three times to discuss the interpretation of background materials and prioritize variables of interest. 

Variables included in the tool were agreed upon by consensus of the group. For the current project, we 

used the tool as a starting point. A small group consisting of a doctor, a nurse, a lawyer and a social 

worker met to discuss the variables and prioritize which variables addressed the needs of the current 

project. Decisions were made by consensus. For the most part, variables where chosen because they had 

been chosen as topics of interest for the training by the curriculum team. The curriculum team used a 

similar modified Delphi method to identify training topics and methods for the training. 

Assigning an overall value to a medical record is impossible given that it may be used in a variety of 

legal settings and for different purposes. We decided instead to identify particular characteristics of 

medical records that would make the records useful to the survivor, or potentially damaging to the survivor 

(which would also tend to make it useful to the perpetrator.) We also recognized that each type of health 

care provider has a different role with the patient and therefore is exposed to different types of information 

and varying documentation responsibilities. To accommodate these differences we developed separate 

tools (abstraction forms) for EMS, Nurses and Residents. A separate tool, the Intake Tool, was created to 

capture information written by either Nurses or Residents since note taking from both providers are written 

in one ED record. All abstractions tools are included in Appendix C of this report. 

We relied on Massachusetts Law and evidentiary rules to inform the tool given the location of study 

sites. First, we identified characteristics that would increase the likelihood medical records admissibility 

based on the medical records exception. Next, but equally as important to our review, we identified types 

of information that would be most useful to patients attempting to obtain legal relief. We prioritized 

factual information that is only available in medical settings. Last, we identified information or 

characteristics most likely to facilitate quality health management. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 55

A table listing the most significant abstraction form items and the rationale for inclusion of each 

follows: 

Abstraction Tool Item Importance of Information as Legal 

Evidence 

Criteria for inclusion We were interested in tracking how victims were 

described in medical records. 

Time, Date and Method of Arrival Establishes the time that patient came into contact 

with hospital which provides a foundation for the 

excited utterance exception. 

What other providers were involved 

with the Patient? 

Is there a team approach to IPV?

Patient’s Gender How does gender play a role in provider’s 

identification of IPV and any response? 

Photographs Photographs are easily entered into evidence. In the 

last project, we found only a few charts that 

referenced photographs having been taken. 

Confidential or Privileged Information In the previous study we concluded that specially 

privileged information should not be contained in the 

main body of the record but should be contained in 

consulting notes or in a special section that could be 

easily identified and protected by medical records 

staff upon release. 

IPV Screen Results from the previous study and focus group data 

indicated that most providers do not screen. Only 

one of the sites actually included a screen in the 

chart. 

Chief Complaint Documenting “DV” as the chief complaint rather 

than an actual medical problem is a common 

occurrence. We hypothesized that it may be more 

likely that patients will be identified if they present 

with a trauma injury than any other reason (e.g. 

medical condition, psychiatric, substance abuse, 

somatic symptoms with no apparent etiology.)

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 56

Abstraction Tool Item Importance of Information as Legal 

Evidence 

Intoxication The focus groups and experience of the 

practitioners/researcher indicated that providers are 

less likely to address IPV if the patient is intoxicated. 

Relationship to the Abuser Results from the last review revealed that providers 

were likely to omit “who” (described by name or 

relationship) committed the act to cause injury and 

health problems. We also wanted to know whether 

the partner was present during treatment since this 

may significantly decrease providers’ ability to 

thoroughly assess and treat a victim of IPV. 

Description of IPV incident We wanted to examine whether providers wrote 

patient’s descriptions of what, where, how, and when 

the IPV event occurred. We also reviewed whether 

the provider paraphrased the incident, used terms 

such as ‘patient reports’, ‘complains of’ or 

‘indicates’, or used quotation marks. 

Inclusion of Legal Terms One common practice among providers is to 

document IPV as an assault, or an act by an assailant 

(without mentioning the relationship to the patient) 

or that the ‘patient alleges’ her partner committed 

abuse. The training would emphasize using only 

well-accepted medical terms in notes. 

Verbal abuse/Controlling Behavior by 

Partner and Present of Partner during 

medical treatment 

One of the primary flaw identified in the previous 

project was providers failing to see how a partners 

controlling behavior can have negative impacts on a 

patient’s health and deter a patient from taking steps 

to improve her health or quality of life. 

Patient’s Demeanor Results from the last project and focus groups 

revealed that providers are likely to omit patients’ 

demeanor under the rationale that a patient’s being 

anything but calm would lessen her credibility 

regarding statements of abuse. 

Physical Exam For residents only (Nurses are not responsible for 

conducting the physical exam and pre-hospital 

providers perform only a limited exam) 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 57

Abstraction Tool Item Importance of Information as Legal 

Evidence 

Description of Injury One of the major deficits identified in the last 

project was providers’ failing to describe injuries 

observed. Most of the records lacked a description of 

the size, location, color, stage of healing, and pain or 

swelling associated with the injuries. Given this is a 

task that is well within providers’ medical expertise, 

we looked to emphasize the importance of this type 

of documentation in the training. 

IPV services offered We tracked how often referrals were made to 

services available within the medical institution, to 

services outside the institution and when no referrals 

were made. 

Referrals made and patient’s response to 

referrals 

Referrals can be made in person, by phone or 

through giving the patient numbers to call. We 

wanted to track whether patients’ responses to 

referrals or intervention were noted and if so if the 

notation was written in a positive, negative, or 

neutral way. 

Discharge Instructions We reviewed how often providers wrote domestic 

violence as a diagnosis, and whether information 

related to IPV or related referrals were written in the 

discharge sheet. 

Legibility, Inconsistencies and 

Incompleteness 

Information related to IPV or signatures were 

reviewed for these problems. 

Observations on the scene Applicable to pre-hospital workers only. 

In the pre-intervention period (Pre-hospital August-November 2001; ED Site #1 January-March 

2002; ED Site #2 March-June 2002), domestic violence was identified in 59 EMS records out of 400 

reviewed, 49 ED Site #1 records out of 14,000 reviewed, and 16 ED Site #2 records out of 8,000 reviewed. 

Only the records reviewed at ED Site #1 captured the entire time period of records. 

Summary of Record Review Findings at Pre-hospital Site

Almost all of the EMS records reviewed were injuries caused by IPV. Four cases were also sexual 

assaults. EMS forms do not include any type of IPV screening prompt but during the pre-training record 

review, EMS employed its own IPV advocate and EMS forms contained a check box for IPV advocate 

referrals. While this check box was not created to serve as a screening tool, it functioned as such. For this 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 58

reason, the check box served as criteria for inclusion. The referral box was checked in a majority of 

records. The regularity of these referrals encouraged us to make referrals to the IPV advocate an integral 

part of the EMS intervention to be presented in the training. 

EMS personnel identified IPV as an issue in the body of 73% of the charts. In most charts (45%), 

patient reports of abuse were paraphrased but in small portions did preface descriptions of events with 

‘patient reports’ or ‘patient complains of (c/o),’ and sometimes used quotation marks. IPV labels such as 

‘Domestic Violence (DV)’ or ‘Battered Woman (BW)’ or euphemisms such as ‘relationship problems’ or 

‘trouble at home’ were used rarely. Only one EMS provider used the term assailant, but many records 

contained the term ‘assault.’ Providers consistently wrote who caused the patient’s injuries (e.g., 

boyfriend, husband, father of kids), the mechanism and the location of the injuries and the abusive 

incident. A significant portion of providers asked about weapons. No providers asked about any kind of 

controlling, isolating or restraining behaviors but a few did make notations about verbal abuse. 

Providers rarely described patient demeanor. In the few occasions where they did, they used terms 

such as ‘angry,’ ‘anxious,’ ‘crying,’ ‘hysterical,’ ‘shaky voice,’ and ‘scared’. ‘Upset’ was the most 

commonly used descriptor. Only a few providers used ‘No apparent distress (NAD).’ Providers 

sometimes described their observations of the scene, including whether children were present. 

EMS providers described injuries usually in terms of the kind of injury, location, and swelling in 

almost 75% of the charts. Providers were less likely to note pain, size or color. One hand-drawn body 

map was included in one record. 

Most of the patients seen were transported to the hospital but a small number did refuse transport. 

Reasons for the patient’s refusal of transport refusal were usually included in the record. Very few 

providers gave patients IPV resources. However, in a small number of cases the EMS IPV advocate made 

in-person contact with the patient during treatment. 

Providers indicated the date consistently but sometimes omitted the time. Police were involved in 

about 20% of the cases which is a much smaller percentage of involvement in EMS calls than indicated by 

providers in previous focus groups. A small number of records contained illegible notes within the body of 

the record. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 59

Summary of Record Review Findings at ED site #1 and ED site #2

A majority of the records identified for review were included in the study because patients had 

reported an injury caused by an abusive partner to the triage nurse. Relatively few were included due to 

positive outcomes from universal IPV screening, a finding that supports other research and reports from 

providers in focus groups. At each of the sites only one or two records were included in the study because 

of IPV screening that was not triggered by a patient report or obvious pattern of injury. 

While only two of the resident physicians completed a positive screen, almost 50% of the records 

showed IPV screens performed by the nurses. The screening tool on the form for one site was ambiguous 

so it was difficult to determine whether a marking on the positive screen meant that the screen was 

completed or that the patient responded positively to the screen. The screening tool was changed during 

the time the trainings occurred which made it impossible for us to make any conclusive statements about 

screening practices. 

In contrast to our previous study, we identified no omissions or inconsistencies with regard to the 

date or time the patient was treated. Accuracy of this type of information can help a patient to establish a 

time period from which to track an abusive event. Additionally, if the time of the abusive event is close 

enough in time to treatment, patient statements properly identified as the patient’s statements through use 

of quotation marks or a notation such as “patient reports” can provide a basis for allowing those statements 

from the record to be considered in a legal setting when under other circumstances they may not. 

 A majority of patients from each site arrived at the ED by their own transportation rather than by 

ambulance. This finding is consistent with the EMT and paramedic reports in focus groups that many 

patients treated by pre-hospital services refuse transport to the hospital or decide on the way to the hospital 

that they will not report the abuse to providers at the hospital. All of the records studied showed patients 

being discharged from the ED, except for those few patients admitted for further psychiatric assessment or 

treatment. 

At ED site #1 approximately 50% of the patients were seen by a consulting psychiatric nurse or 

doctor, and only 17% were seen by a social worker. At ED site #2, patients were likely to see either a 

psychiatric doctor or a social worker but not both, and each occurred with equal frequency (4 out of 16 

patients). In 15-20% of the cases police were involved, due to transporting the patient to the department 

or responding to a request from the medical staff. Security was involved in 25% of the cases at ED site #1 

but was only involved in one case from ED site #2. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 60

At ED site #2, about 1/5 of the records contained inconsistencies. While a few of the records 

included contradictory descriptions of how the patient was injured or the mechanism used (e.g. “boyfriend 

threw a lamp at her face,” versus “boyfriend hit her in nose with snow globe,”) most of the inconsistencies 

occurred in the way that various providers depicted the abusive person’s relationship to the patient. An 

abusive partner could be labeled boyfriend, significant other, husband and father of children 

simultaneously within the same record. While the record indicated there was only one perpetrator of 

abuse, a husband who was actually the perpetrator could later argue that it was a boyfriend who actually 

committed the abuse. 

In at least 1/3 of the records at each ED site, photographs would have been helpful to memorialize 

patient injuries, however, only three patients at ED site #1 had photographs taken by domestic violence 

advocates providing consulting services to the medical providers and no photographs were taken at ED site 

#2. Only one record contained a hand-drawn body map. 

At ED site #2, 3 out of the 16 records were incomplete, missing either a resident note or discharge 

information. This may have been the case because the patient was an employee who has been assaulted 

while working or because the patient had absconded prior to conclusion of assessment and/or treatment. 

However, an explanation for an incomplete record were not noted anywhere in the record, thereby 

exposing the institution to liability. Only a few patients indicated the need for an interpreter, but according 

to their records none of them received hospital-based interpretive services. 

Eighty percent of the patients from ED site #1 were women, most of who identified as heterosexual. 

The remaining 20% were men, none of whom were identified by staff to be gay. A majority of the patients 

from ED site #2 were identified as heterosexual women while a few patients identified as gay men. None 

of the patients identified as bisexual or transgender. Less than 10% of the women patients at each site 

were pregnant. Many of these women were unaware of their pregnancy prior to their visit. 

The most common chief complaints noted in records reviewed at both ED sites were ‘injury domestic 

violence’ or ‘status post assault’ (s/p assault). Only one of the providers who wrote “s/p assault” also 

described the specific injury resulting from the assault. Residents were slightly more likely to write 

‘domestic violence’ as the chief complaint than the nurses. It appeared to be common practice for 

providers to note substance abuse or mental health diagnosis (oftentimes ‘suicidal ideation’) as the chief 

complaint even when IPV was reported as the patient’s primary complaint. A stark example of this was a 

case involving a woman who presented with multiple injuries in various stages of healing and reported 

being raped by her boyfriend. However, after reporting that she had been prescribed an anti-depressant 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 61

within the last two years and refusing to participate in the Sexual Assault Nurses Exam (SANE), she was 

diagnosed as delusional and paranoid and referred for a psychiatric assessment. While these patients may 

have needed psychiatric attention, there was no indication in the records that the IPV was also being 

addressed. 

The nurses at both ED sites were more likely than residents to describe the patient’s relationship to 

the abusive person. Less than 10% of the records indicated that the abusive partner was present at the ED 

site during treatment. 

Nurses and residents at both sites were equally as likely to paraphrase incidents of abuse rather than 

use quotation marks or write ‘patient reports or c/o ’. Fragmented notes such as “beaten”, “kicked during 

argument,” or “fell down stairs during fight,” are examples of paraphrasing. Less than 30% of the 

descriptions included who committed the abusive act, when it happened and how it occurred (e.g., kicked 

with a boot, punched repeatedly). About 20% of providers asked about whether weapons were involved. 

Surprisingly, residents were much more likely than nurses to note who committed the abuse, when the 

events occurred and provide details about how the abuse occurred. Only two nurses and two providers 

from ED site #2 asked patients about the type of force used. 

Nurses and residents frequently used legal terms such as assailant, assault, and alleged. Resident 

notes was illegible in more than 30% of the records at both sites. Nursing notes from ED site #1 were 

illegible only 10% of the time and there were no illegible notes in any of the nursing notes at ED site #2. 

Even though nurses appear to do much more documentation than the residents, their writing was 

consistently much more legible than the residents. Resident signatures were illegible in almost 50% of the 

records while nurses signatures were illegible in 20% of the nurses at ED site #1. 

At both sites 30% of the patients identified as victims of IPV had recently used ETOH or presented 

intoxicated. Aptly, one provider included a qualifying note, “clinically sober despite + ETOH.” A note 

like this accurately addresses any alcohol intake by the patient but serves to preserve the patient’s 

credibility regarding any statements or presentation made to ED staff. 

None of the providers at ED site #2 identified any controlling behaviors while residents and nurses at 

the ED site #1 noted controlling behaviors in three records. 

Residents were much more likely than nurses to describe patients’ demeanor. Residents were most 

likely to write “NAD”(no apparent distress) while nurses almost never used this term. Nurses and 

residents who described demeanor used terms such as “anxious,” “crying” or “upset.” Only one resident 

used the term “flat affect.” Terms with negative connotations such “uncooperative,” “hostile,” “agitated,” 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 62

“combative,” and “angry,” were only used once or twice in all the records. When descriptions were 

included, they were often quite detailed. Patients’ fear was identified only once out of all the ED records 

reviewed. Providers seemed more likely to ignore the issue of IPV when the patient was upset, angry or 

hostile. Rather than documenting identification of IPV, assessing injuries or treating the injuries, providers 

seemed to focus their documentation on detailing the patients’ offensive behavior and steps taken to 

restrain the patient. 

Providers were even less likely to write detailed notes about patient injuries. Most providers 

described the kind of injury incurred (e.g., cut, abrasion, bruising) when it was visually apparent and in 

those cases almost half of the records contained the location of the injury. However, only a small number 

of nurses and resident physician noted the color, size, swelling or pain associated with an injury. 

Nurses were much more likely to make a referral to a consult inside the hospital (53% of records) 

where resident physician were more likely to make a referral outside the hospital (10% of the records). 

More of the referrals were made person to person rather than giving the patient a phone number. No 

referrals were made by phone. Patient’s responses to services were not noted by any of the residents and 

only noted by 10-15% of the nurses at both sites. 

In more than 50% of the records from ED site #1, residents documented conducting a full physical 

exam, whereas only 30% of ED site # 2 residents did so. 

At ED site #1, domestic violence was written as the diagnosis in 17% of the records, and details 

regard interventions related to IPV or follow-up were included in 30%. S/P assault was written as the 

diagnosis for 20% of the resident discharge notes at ED site #2. 

Many of the records that showed indicators of IPV could not be included in the study because the 

perpetrator of the abuse was unclear. The most common examples of an unnecessary ambiguity include, “ 

patient fell over table and broke her arm”, “punched in face,” “kicked in head,” and, “towel wrapped and 

tightened around neck leaving red marks.” In all of these examples, the very important detail of who

committed the acts causing injury was omitted. While the name of the person is optimal to reduce any 

ambiguity upon subsequent review of the record, naming the relationship between the abusive person and 

the patient (husband, live-in boyfriend, boyfriend, father of children) is also a very helpful. 

Many records also had to be excluded from the study because the abuse was generally described as 

“problems at home,” “family problems,” “hurt at home,” or “ trouble with man he is living with.” Despite 

indicators of IPV, it was impossible to determine whether abuse had been caused by an intimate partner, 

family member, or roommate. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 63

We did not include data contained in the consulting notes of psychiatry, social work or other 

providers since these providers would not to participate in the training. However, the notes of these 

providers were useful to determine the kind and extent of information omitted from nursing and resident 

physician notes.

Conclusions from Data Collection for Curriculum Development 

 Providers seem to know how to recognize physical symptoms of IPV. However, they assess 

and treat the patient is not clear from documentation. Crucial information related to health 

care needs such as extent, location and type of injuries is often missing. A brief 

generalization about abuse (b/f hit in face) is repeated throughout the record. 

 Anyone can ask the questions relating to IPV – the difficult task comes in determining what 

to do when a patient confirms he or she is experiencing abuse. Providers need to know more 

about how to respond and how to document their response. 

 Addressing IPV without proper tools and resources is overwhelming for any professional. 

Current protocols and recommendations can only be adhered to if providers are trained, have 

adequate resources in the setting and are familiar with resources to make referrals with 

confidence. 

 Providers who are not trained to do IPV counseling or safety planning are not making the best 

use of their time by trying to accomplish these tasks. Health care providers are equipped to 

do so many other things that are helpful to the patient. Specially trained advocates and social 

workers are better situated to provide counseling, safety planning and assist patients to 

consider options. Sending messages to the patient that she or he is believed, abuse occurs to 

many people, and special services to address this problem are available is an important 

intervention that takes little time or training to execute. An outsider presenting these ideas 

may give a patient a new perspective and inspire her to consider seeking help from IPV 

services. 

 Careful assessment and documentation is an intervention -- a valuable one that can help 

patients weeks, months or years after treatment when patients are better prepared to take steps 

to eliminate the violence in their life. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 64

 Providers’ attention to and time spent on IPV should not be conditioned upon a patient’s 

willingness to disclose abuse. Providers should not interpret patients’ silence as resistance to 

or rejection of providers’ concern. Any help-seeking steps, including seeking medical 

treatment, creates a risk to the patient of retaliation by the abusive partner. Fear of what the 

abusive partner would do if he found out about abuse may prevent a patient from disclosing, 

regardless of provider attributes. 

 Pre-hospital providers, nurses and resident physicians perform very different functions and 

have different intervention and documentation opportunities with patients. Trainings must be 

tailored to address these differences. 

Creating the Curriculum 

The training team was made up of two doctors, a social worker and an attorney. All members had 

extensive experience in developing IPV curriculum and delivering training to medical providers and others 

working in medical settings. Three of the members worked extensively on the previous study, Legal 

Evidence Project 2002. The team was presented with a summary of the most commonly used training 

tools, pre-intervention focus group data, and record review results. After several meetings, the team 

identified nine training priorities, determined the most effective methods for presenting various topics and 

outlined the training. 

The training priorities identified included the following: 

Priority One: 

Present IPV as a health care issue. Increase providers’ knowledge of various efforts to respond to 

IPV in various medical settings. Increase providers’ understanding of the impact of IPV on patient’s health 

and the cost of ignoring IPV medical settings. 

Priority Two: 

Help providers to understand the importance of learning from patients. Share patients’ perspectives 

regarding how certain behaviors or responses could benefit patient health care and patients’ ability to 

increase safety and well-being. 

Priority Three: 

Create realistic expectations of what can be accomplished for patients who are seeking help in 

emergency care settings. Most survivors will not and should not make significant life decisions or drastic 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 65

change in their life when in crisis subsequent to abuse that requires medical care. Providing patients with 

an opportunity to share what is happening to them, treating them with respect, attending to their medical 

needs, documenting their treatment and sharing resources is a comprehensive intervention. No service 

providers can make a patient safe or change a patient’s life during the time allotted for treatment in these 

settings. Share the model of brief advice and referral used by domestic violence advocates.

Priority Four: 

Introduce a team approach that enables providers to do as much as time allows with each patient, 

even if that means not performing every intervention step possible. Teach providers to prioritize activities 

and make referrals to others when time is limited. Emphasize that performing one aspect of an 

intervention well is more likely to have a positive effect than touching on every aspect superficially or 

doing nothing at all. 

Priority Five: 

Addressing providers general and specific concerns related to addressing IPV, including patient 

privacy and safety issues, interviewing skills, referral and resources information, and liability. 

Priority Six: 

Identify and discuss concrete assessment, treatment and documentation strategies. Use real examples 

shared by the providers to identify intervention and documentation strategies they can be implemented in 

their everyday practice to reduce their concerns. 

Priority Seven: 

Emphasize the benefits and efficacy of employing a client empowerment approach rather than a 

medical model approach to IPV. 

Priority Eight: 

Address safety in the department and attempt to find support for providers from ancillary staff on 

site. 

Priority Nine: 

Comprehensive medical documentation of IPV may enable patients to get the help they need to end 

the violence in their lives. Good medical record keeping can also prevent a provider from testifying in 

court or can make testimony much easier. 

All decisions regarding the curriculum content and presentation were made by consensus. Whenever 

consensus was not reached, we presented each approach and described the benefits and risks associated 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 66

with each. An example of this was the use of DV as a chief complaint or diagnosis. While the designation 

of DV does apprise anyone reading the record that abuse is an issue, it is not useful unless other 

information relating to the abuse is also included in the record. Many providers mistakenly see this 

designation as complete documentation of IPV and fail to document relevant information that would be 

useful to other providing on-going care. Additionally, notation of DV in the record, without accompanying 

notes, would not be helpful to a patient in legal settings without requiring that the provider interpret the 

note through in-person testimony. Because there was some disagreement about whether noting DV 

somewhere is better than no documentation at all, we included a discussion of the “pros” and “cons” of this 

practice in the training. For the most part though we were able to shape each topic in a way that satisfied 

each member’s concerns. Once the core training was completed, the team met four more times to tailor the 

core training to each provider group (EMS, Nurses and Residents), refine presentation methodology and 

choose resource materials for dissemination. 

Over the course of creating the training, we determined that that it would be difficult to address the 

nine training priorities identified in a single 50-minute training. For this reason, we carefully documented 

our rationale for training and planned to present findings to interested parties at each study site in hope that 

someone from each site would continue training efforts after the conclusion of our project. 

Delivering Training to Providers at Three Sites 

All trainings were presented in power point incorporating interactive activities, documentation 

examples, photographs, body maps and/or video clips. We implemented various adult learning strategies. 

Our goal was to build on information and skills providers already possessed and to provide new 

information of interest to them (e.g., tips on how to interact with lawyers, prepare to testify in court, avoid 

testifying in court through complete record keeping and reduce risk of liability.) We sought to convince 

providers that responding to IPV is an essential part of quality medical care. This curriculum assumed that 

providers had experience in recognizing signs of abuse. The training focused on how to respond to IPV 

once it was identified rather than universal screening. 

In order to accommodate providers’ schedules and coordinate trainings with record abstraction 

timelines, trainings for providers at each of the sites were conducted from November 2001 through April 

2003. Pre-hospitals providers were the first to be trained in November and December of 2001. Trainings 

were included as part of an eight-hour annual training program intended to reach all EMS providers. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 67

Trainings were held at 7:30 am, 8:30 pm, or Midnight. Pre-hospital providers who participated were paid 

as though they were working out in the field and fulfilling an otherwise required training segment. As a 

result, we trained 237 EMTs and Paramedics (78%). 

Training for the residents at each site were conducted as part of weekly rounds. All residents who 

were not working, visiting at another hospital or on approved leave were required to attend these meetings. 

We trained 23 residents (59%) at ED Site #1 in April 2002 and 16 residents (57%) at ED Site #2 in April 

2003. We were permitted to present the training at one weekly rounds. We offered several alternative 

training times to residents who were unable to attend the weekly rounds but no one expressed a willingness 

to attend the extra sessions. 

Training the nursing staff at each site was far more challenging than the research team originally 

anticipated. We worked extensively with nursing management at each site to determine feasible training 

times. In order to train 48 nurses (80%) working in the ED of Site #1, we held 24 trainings over a 4-week 

period from May-June 2002. Trainings were delivered at 5 am, 7:30 am, 11 am, 2pm, 3:30 pm, 7 pm, or 

11pm so that providers could attend during a break, right before or right after their shift. Seven of the 

trainings offered had 0 attendees. The other trainings averaged 3-5 attendees. At site #2, 41 nurses (51%) 

were trained as a result of 16 trainings offered over a 4-month period from January-April 2003. Trainings 

were delivered at 7:30 am, 11:00 am, Noon, 1 pm, 2 pm, and 3:30 pm. Eight of the trainings offered had 0 

attendees. The other trainings averaged 3-5 providers. 

Providers at each site were considered in attendance if they participated in at least 75% of the 

training. Because training was offered during shifts in order to achieve attendance, some staff were called 

out of the training to treat patients. EMTs and Paramedics included all permanent staff working at the prehospital services site. Residents included only those residents who were permanent and formal members 

of the residency program. Nurses included full-time, part-time, per diem, SOL, and visiting nurses. 

Nurses from the Pediatric division at Site #1 also attended the training but were not included in any other 

aspects of the study. Nurses at each site received 1 hour of continuing education credit for attendance at the 

training. 

At the conclusion of each training, each provider was given a palm card, and each department 

received five “Help” Books (a comprehensive directory containing local IPV resources), a Polaroid camera 

and a supply of film. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 68

Post-Intervention Record Review 

The goal of this project was to improve quality of documentation of IPV among providers. Our 

evaluation was conducted to determine the effect of the documentation training on the quality of 

subsequent record keeping of those who attended the training. While we anticipated this training would 

have a ripple effect on the entire departments studied, we did not evaluate this effect. To obtain baseline 

data, we reviewed records of all providers from each department. To obtain post-training data we 

reviewed only those records of providers who attended the training. Pre-training records from the prehospital site were abstracted from August - November 2001 and post-training records were abstracted from 

January – May 2002. Pre-training records from ED Site #1 were abstracted from January – March 2002 

and post-training records were identified from April-June 2002. Pre-training records from ED Site #2 were 

identified from March – June 2002 and post-training records were identified from February 2003 - June 

2003. 

Identification Process 

All adult patient records that fit study criteria and involved at least one provider who attended the 

training were reviewed and compared to records collected prior to the training. The records were 

abstracted as a whole rather than focusing only on the documentation of the provider(s) trained. The prehospital records and records from hospital ED site #1 were abstracted by the same research assistant who 

abstracted the pre-training records using the same decision rules and access database. 

At the pre-hospital site, we identified 45 post-training pre-hospital records to compare to 59 pretraining records. At ED site #1, we identified 48 post-training records to compare to the 59 pre-training 

records. At ED site #2, we identified only 16 pre-training records and 20 post-training records. Given the 

limited statistical analysis permitted using such a small number of records, records from ED site #2 were 

not abstracted or compared statistically to ED site #1 records. Instead records from this site will be 

described qualitatively later in this section. 

We used three different mechanisms to identify post-training records at each of the three sites in 

order to accommodate each setting’s record storage system. At the pre-hospital site a person responsible 

for flagging all potential IPV cases flagged these records and a research assistant reviewed records to 

determine which records satisfied study criteria. In the other two sites, research assistants reviewed 

individual records for a three-month period. 130 pre-hospital records were reviewed to yield 70 records 

meeting the criteria. At ED site #1 12,000 records were reviewed to yield 59 records, capturing the entire 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 69

time period. At ED site #2, 8,000 records were reviewed to yield 16 records, capturing records from 

various times of each day during the period of review. Due to limited resources and strict time restrictions, 

we were unable to devote any more resources or time to identifying additional records. 

Abstraction Process 

Variables of interest were selected by a modified Delphi method as described in the pre-training 

record review section above. Decision rules were formulated into a manual, and an abstraction form was 

created in Microsoft Access® for direct data entry using a laptop computer. After training and piloting, 

two abstractors entered data independently. Results were imported into SPSS for descriptive analysis. Chisquare methods were used to evaluate differences between pre and post training performance. 

Four distinct chart elements were abstracted and analyzed: EMS records from the Pre-hospital site 

and the intake, the nursing, the physician notes from IPV cases identified at ED site #1. While the EMS 

dataset may have included some patients who were subsequently treated at ED site #1, many EMS patients 

were transported to other ED sites that were not involved in the study. For this reason, we did not link 

EMS records to ED records. 

Results 

Findings from each site are described below. Implications of the results are described later in the 

record review conclusions. 

Pre-Hospital Records

We abstracted 118 EMS records, 48 from the pre-training period and 70 from the post-training 

period. We tracked items related to intake (date, time, names of persons at the scene, description of the 

scene, and chief complaint), statements about causality (identification of domestic violence and sexual 

assault, and patient statements), event descriptors, physical exam descriptors with particular reference to 

injury, statements about the patient’s demeanor, and treatment/disposition items. Significant 

improvements were noted in 12 items from the pre-training to the post-training period. EMS providers 

were more likely to identify domestic violence (97% vs 73% of the time, p=.000). They were more likely 

to write the patient’s name legibly (100% vs 88%, p=.004). They also were more likely to describe 

abusive incidents, and using reporting language (63% vs 45%, p=.05), and ‘the patient discloses...’ (54% 

vs 8%, p=.000). Providers paraphrasing patients’ reports of abusive events (46% vs 45%, p=.017) also 

increased, despite training recommendations to write patient reports specifically. However, while the 

format of the describing the abusive event is not optimal, the fact that the incident was not omitted 

altogether is a positive outcome. They were more likely to chart who (97% vs 75%, p=.000), what (99% 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 70

vs 77%, p=.000), and why (97% vs 69%, p=.000). Descriptions of the injury were also more common in 

the post-training period (93% vs 67%, p=.000), especially location (96% vs 73%, p=.001) and pain (57% 

vs 25%, p=.000). 

ED Site #1 Records

Intake 

Intake records were examined for 59 domestic violence cases from the pre-training period and 48 

from the post-training period. Over a third of these cases (35%) were accompanied by documented injury, 

and 40% arrived by ambulance. Charting elements that were evaluated include accuracy of record for 

name, date, time, gender, address and language barrier. Confidentiality warnings to protect address were 

also noted, as was residence in a shelter. Documentation was ascertained for involvement of a domestic 

violence advocate, psychiatrist or psychiatric nurse, social worker, interpreter, hospital security guard or 

police officer. Documentation of photography was noted. Handling of sensitive information (past or 

current substance abuse, STDs, HIV/AIDS and pregnancy) was evaluated. Consults with other services 

were noted. Abstractors also counted the number of contradictions within a patient’s record. Finally, 

discharge status was noted. 

On four of these items, there was a distinct improvement after training. Charting of psychiatrist’s 

involvement improved from 0% to 6% (p=.09) and for psychiatric nurses from 21% to 50% (p=.005). 

Consistent charting of the patient’s name improved from 93% to 100% (p=.085) . Documentation of 

appropriateness of photographs increased from 11% to 42% (p=.000). 

Nursing Notes 

Nursing records were examined for 59 domestic violence cases from the pre-training period and 48 

from the post-training period. Items tracked in nursing notes included the triage encounter (chief and 

secondary complaint and notes about intoxication), the event description, the description of the patient’s 

demeanor, the description of the injury, provision of domestic violence services, and the nursing discharge 

note. 

There was improvement in 13 variables from the pre-training to the post-training period. In the posttraining period, the perpetrator was identified by relationship to the patient much more frequently (71% vs 

20%, p=.000), and documentation of the partner’s presence increased from 14% to 65% (p=000). Notation 

of crying increased from 7% to 21% (p=.032), and documentation of demeanor increased from 20% to 

48% (p=.002). Domestic violence was more likely to be listed as the chief complaint (48% vs 20%, 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 71

p=.003) or secondary complaint (39% vs 32%, p=.000). Nurses were more likely to use reporting language 

i.e. patient reports or states, patient told me (40% vs 24%, p=.06). They were also more likely to describe 

the force that resulted in injury (46% vs 3%, p=.000), and they were more likely to provide the patient with 

the diagnosis of domestic violence at discharge (38% vs 20%, p=.04). In the post-training period, none of 

the charts contained illegible information, compared to 12% illegible in the pre-training period (p=.013). 

Domestic violence terms were used 63% of the time post-training, compared to only 40% in the initial 

period (p=.003). Finally, there was improvement in the charting of the perpetrator’s use of alcohol in 

association with a domestic violence event (15% vs 2% pre-training, p=.014). 

Resident Records 

We abstracted 59 physician records from the pre-training period and 48 from the post-training period. 

Items tracked were similar to those reported for nurses, but included more extensive detail of the physical 

examination. Physician reporting quality was decreased overall, reflecting an increase in patient numbers 

and acuity and accompanying stressors on physician time, but there were improvements in 6 measures. 

Physicians were less likely to chart ‘no apparent distress’ or NAD (down from 39% to 14%, p=.004) or fail 

to chart patient attributes (down from 46% to 16%, p=.001). They were more likely to list DV as a chief 

complaint (55% vs 25% in the initial period, p=.006). They were more likely to note the use of alcohol by 

the perpetrator (12% vs 2%, p=.031), and less likely to write a blanket statement of intoxication for the 

patient (2% vs 12%, p=.057). They were also more likely to describe the extent of force that resulted in an 

injury (21% vs 3%, p=.005). 

Qualitative Description of Hospital ED Records from Site #2

We identified only 20 IPV records written by either a nurse or resident who attended the training. Of 

the 20 records, 5 included notes of trained residents notes and 16 included notes of trained nurses. 

Record review indicated improvements in 9 measures. Nurses decreased their designation of ‘s/p 

domestic violence’ or ‘domestic violence’ as a chief complaint, a common mistake in pre-training records 

that we emphasized in the training. Nurses decreased their use of legal terms such as assault or assailant. 

Nurses and residents also increased taking photographs and drawing body maps, although the increase was 

only slight (one photograph and one body map of past injuries). Providers were more likely to include 

descriptions of abusive events, using quotes and ‘patient reports.’ Providers also increased documentation 

of an abusive partner’s presence in the ED. Legibility of the note taking also increased. Similarly to ED 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 72

site #1, more providers used descriptive terms to describe demeanor and decreased their use of “NAD.” 

Unfortunately, many of the terms were negative rather than positive or neutral in nature. Providers 

increased describing injuries, including location, swelling and pain. This is a drastic change from preintervention records which tended to focus on the abusive behavior (e.g., “punched by partner) rather than 

the injuries or health impacts of the abusive behavior. Providers made more referrals to in-hospital IPV 

services but failed to make notations of these referrals specifically in the record. Additionally, more 

records included neutral notes regarding patient response to services offered. 

The only negative difference in post-training records is that several records did not contain the date 

of treatment. We did not emphasize this element in the trainings because it was not a problem identified in 

the pre-training record review at any of the sites. However, this finding is consistent with the results from 

Legal Evidence Project 2002. 

None of the records contained inconsistent notes regarding the patient’s relationship to the abusive 

person. However, we did see inconsistent descriptions of the abusive incident that preceded treatment in 

two patient records. 

Record Review Conclusions 

In this outcome assessment, we attempted to measure the effect of training on a segment of the EMS 

and ED study sites. Results are interesting if somewhat attenuated. Several important improvements 

appeared in records from each site. 

Improvements

IPV identification increased despite the fact that routine screening and the use of screening tools was 

not a topic of the training. Despite the low numbers of IPV records identified for review, the number of 

records pre- versus post- suggests that the training may have increased identification overall, especially in 

ED site #2 where no more than half of the providers were trained. We were able to identify more or the 

same records at all sites even though the pool of records eligible was reduced by at least 20% given only a 

portion of each provider group received the training. Another important change in practice was that 

providers increased their descriptions of abusive incidents and used reporting language and specific details 

more often. Providers also reduced their use of non-descriptive terms of demeanor such as “NAD” and 

increased their use of specific demeanor descriptions such as ‘upset’ and ‘tearful.’ Legibility also 

increased and the providers also seemed to recognize the importance of detailing injuries more thoroughly, 

including using drawings and photographs. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 73

On-Going Problems

Problems in documentation included providers’ not specifying who caused an injury to the patient, 

failing to document past injuries, and omitting detailed descriptions of injuries. Providers also failed to 

address IPV when psychiatric symptoms or substance abuse problems were also present. Provider notes 

also indicated little time spent addressing the health impacts of abuse. While some notes described 

providers’ notifying patients of resources or offering to call the police, none of the notes indicated that 

providers described the health impacts or potential risks to health caused by abuse. 

While all providers recognized that documentation is essential for good clinical care and seemed to 

understand how documentation could help IPV victims access protective relief, most providers raised 

several obstacles to thorough and consistent charting during the training. What was clear, even from poor 

records, is that providers recognize when patients are experiencing abuse and treat them differently. Data 

from this project suggests that physicians want to give quality care but are resistant to developing skills and 

new habits to address IPV. 

Inability to Isolate Documentation Skills from Quality of Response

Unfortunately, since the focus of this study was on documentation, we are unable to ascertain the 

quality of care apart from documentation strategies. It may be that providers’ behavior has changed but 

their documentation skills did not change significantly enough to indicate the change in behavior. One 

study in progress indicates that providers who spend their time making a change in the way they deliver 

service may have less time or feel less capable of documenting their accomplishments (McCloskey, 2003). 

We suspect that changes in practice must occur before we can expect a significant change in how those 

practices are documented. Additionally, any educational process to expand the skills of providers must be 

accompanied by changes in forms to make documentation more efficient including triggers, designated 

areas for documenting important information, and a standardized abbreviations list consistently used by 

providers. For example, when items have to be initiated by the practitioner, the record may continue to be 

less than complete, even following successful training experiences that result in a change in practice. 

Challenges Faced

We faced several challenges in implementing the training and evaluation. We were unable to 

mandate that providers attend the training and did not have the resources to pay them for their attendance. 

Had we been able to train more providers, our results would be more conclusive. Additionally, patients in 

the study were seen by a team of 3-6 providers depending on the time of day the patient presented for 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 74

treatment. Since documentation in each department is performed as a team, our results may have been 

diluted by not training all providers. Saturation would have increased the impact on the department overall 

and may have reinforced recommended behaviors. 

We also anticipated that a higher rate of patient cases would fit our criteria for IPV. Another factor 

out of our control was the number of women presenting to each site with IPV and whether patients were 

treated by trained providers. The time restrictions imposed by the schedule of the residents combined with 

the length of time it took to identify records to review proved to be more obstructive to the methodology 

than originally anticipated. Residents work together for one year from June-July. In order to capture as 

many residents as possible, we needed to accomplish all of our work within that year and also 

accommodate the residency program schedule. Other institutional changes that proved problematic were a 

dramatic change in medical record forms at one site and significant budget cuts and lay offs of nurses at 

another site. 

Training and Resources Needed to Implement an IPV Protocol in an Emergency Care Setting

Originally, we anticipated that providing IPV training to the target groups of providers would be 

easily attainable. One of the unintended but important outcomes of our project is the exploration of the 

feasibility of implementing and evaluating an IPV intervention in an emergency care facility. While we 

have yet to truly ascertain the effectiveness of the intervention to improve documentation through a larger 

scale study with a higher percentage of providers trained and more records studied, we have learned many 

valuable lessons related to the feasibility of conducting a full-scale intervention in an emergency setting 

that is open for business 7 days a week, 24-hours a day. We have also learned much about what types of 

information providers are looking for, incentives for changing behavior and provider behavior that is 

preferred by patients. Lessons and recommendations are described in a later section of this report. 

To learn more about provider’s opinions and attitudes about the training, focus groups were 

conducted at each of the sites. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 75

Post-Intervention Focus Groups 

Background

Purpose. Focus groups were used to assess the impact of the documentation training intervention on 

provider attitudes and knowledge. The focus groups also provided a forum for providers to “vent” about 

difficulties they are having with documentation. This feedback provides critical information for refining 

the training and planning “refresher” sessions. 

Groups. Seven focus groups were conducted between January and December 2003. These groups 

took place from six months to a year after the training intervention. There were two groups of physicians 

(n=4 and n=2), four groups of nurses (n=4, n=3, n=4, and n=4), and one group of Emergency Medical 

Technicians (EMT) (n=10). We worked with the clinical coordinators at each site who recruited 

participants who had taken part in the intervention training. The groups varied in time from 30 to 80 

minutes. Most were about an hour. Recruiting and scheduling the groups in an ER setting was difficult, 

resulting in small numbers. The groups were tape recorded and transcribed. No individual comments are 

identified and names were removed from the transcripts. It is important to emphasize here that conclusions 

based on these groups must be tentative because of the small numbers—particularly in the size of the 

groups in which an individual voice can have a disproportionate influence. It is noted in the discussion 

which comments were made across most groups and which were made by only one or two people. 

Demographics of the Sample. Thirty-one providers participated in the groups. There were six 

physicians (three females, three males), fifteen nurses (12 females, three males), and 10 EMS providers 

(three females, seven males). In sum, 18 females and 13 males participated in the groups. The age range 

of the participants was 26 to 54, with a mean of 40. Years of experience as a health care professional 

ranged from three to 32. We asked the participants about prior interest in or experience with domestic 

violence. Eleven responded with “none.” Twelve left the question blank. Eight participants wrote in 

comments. Five of the comments indicated experience with domestic violence was a part of their job. One 

said “limited;” one said “yes;” and one indicated being a volunteer at a battered women’s shelter. There 

was some variability among the professional groups by age and years of professional experience. The 

physicians (mean age 31) were significantly younger than the nurses (41) and EMS (42). The physicians 

also had significantly less professional experience (5 years) than the nurses (16 years) and EMS (21 years). 

This is not surprising as the physicians in the groups were Residents. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 76

Organization of the Data. The qualitative data from the focus groups are organized into four 

sections: 1) the providers’ recall and opinions of the training; 2) experiences with domestic violence and 

documentation issues—major and sub-themes; 3) suggestions for better documentation and further 

training; and 4) implications for future interventions. 

Recall & Opinions of Training 

Recall of content. The recall of content varied both within and among provider groups. Some 

providers gave detailed accounts of what they learned, others remembered less. Some of these focused on 

the training bringing awareness to them about screening for domestic violence, but had little recall of the 

documentation issues. One provider noted, “I remember very little.” A small number of providers 

remembered inaccurately—“put patient alleges....” “write nothing down except medical stuff.” Overall, 

recall appeared better than average, particularly given the training had occurred six to twelve months 

earlier. Almost all providers wanted refresher courses or further training. 

Physicians’ recall of the content of the training was good. Overall they listed the main points of 

documentation content: physical exam—write everything you find, be specific and detailed, size and 

location of injuries; how to approach the topic; verbatim accounts from the victim—“woman states,” not 

“alleges”; never put your thoughts or opinions in account—omit non-factual, subjective; be more 

inclusive—e.g., the name of the person. One physician noted, “Now I say, ‘Twenty-two year old woman 

struck by so and so, her boyfriend, three times on face with closed fist.’” 

Nurses’ recall of the documentation content was also fairly good, but with an additional emphasis on 

awareness and screening issues. One nurse responded to the recall question with, “It opened up my vision 

of who could potentially be a victim, and that is what I took home with me the most.” Another 

commented, “I can remember vignettes on tape...good for interview purposes...but I can’t remember what 

they told us about documentation....I thought the emphasis was probably more on getting us to ask the 

questions.” All four of the nurses’ focus groups commented on awareness and screening during the recall 

question. As nurses are the first contact for most patients and usually expected to do the screenings, this is 

an expected focus. In addition they recalled the steps to go through when a domestic violence patient is 

suspected or identified. Some also noted being educated about the complexity of the process of change for 

abused women. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 77

EMTs’ recall of the content appears confused. More accurately, there was a great deal of debate and 

disagreement about what the documentation training actually wanted them to do and whether that was in 

conflict with their EMT training. Many believed it was. This will be discussed in detail below. However, 

some EMTs clearly understood the main thrust of the training. “Document injuries to substantiate 

allegations.” “...put patient states X,Y,Z did this.” 

Opinion of training. Opinions of the training were wide and varied. A number of providers in all 

professional groups thought the training was too long and repetitive and that it should be condensed. One 

thought it was too short. Another said that repetition and reinforcement is how they learn. Another 

thought it was a good review. Most providers liked the vignettes/case studies and discussion that 

illustrated what should be documented and what should not be documented. In addition they appreciated 

real examples of what actually helped or hindered a victim legally. “When writing notes now I think of 

it...[and]...want it very descriptive. I think that’s what people see, something that is shocking to them or 

something that stands out that this is wrong and someone clearly meant to hurt this person.” They all want 

further training. 

The EMTs felt the trainer did not understand the context in which they work. “The trainer has to 

know what we deal with day to day—what goes on, on the street—it’s not a hospital, clean, secure, warm 

environment.” “...nobody can sit there and tell us what we have to do or what we should do without the 

benefit of knowing what we do, and 99% of the people that come and give us these lectures don’t have a 

clue.” They explicitly described it as a barrier to communication. “They tell you what your job is and 

what to do, and they have no idea what you’re going through.” One of the nurses expressed a similar view, 

indicating the trainer did not understand the ER context and couldn’t appreciate the medical side of the 

battered woman. Describing a case in which a woman died from a beating and they had to deliver the 

baby, one nurse said, “I mean, you have to make sure they live.” 

In one of the physician groups there were two different takes on the same training. The two male 

physicians felt cautioned by the trainer not to put down anything negative about a domestic violence 

patient—e.g., “unreliable” or “impaired” or “combative.” As one said, he felt “pressured to paint a picture 

that would help the patient later.... even if I didn’t feel it was 100% accurate.” The two female physicians 

responded, “I think the guys kind of felt that way and we never felt that way.” The female physicians felt 

they should put down information like “intoxicated” or “uncooperative”—what is actually going on—and 

that they should “be aware that there are things that you can say that will suggest what you were thinking, 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 78

and to avoid that, and to be aware that if you do use those things that you can then be harming the 

subject....” 

In two of the nurses’ groups they commented on the chaos of being trained in the ER with nurses 

coming and going to check on patients, or coming off a night shift to the training, and being too tired to 

take it in. One nurse noted that doing the focus group itself required having four extra nurses on so they 

would not have to leave the group to deal with patients. They appreciated having clear steps to go through 

in dealing with domestic violence cases, as well as concrete suggestions for ways to talk to abused women. 

For some, being educated about the complexity of change helped to reduce their own frustration and “keep 

the door open” for women who were not yet ready to publicly confront their abuse. One nurse indicated 

that the actual information delivered was good, but that it wasn’t designed for the ER environment. 

“...Hers was the perfect world sort of thing, where you can take someone and separate them and talk to 

them and spend time. Triage can’t do that....” “So when the woman said well, statistics show that most 

battering happens in the late evening and early morning, I’m getting annoyed ‘cause I’m saying so why do 

we have a battered women’s advocate working 8 to 4?” 

The EMTs’ opinions of the training were complicated by the perceived conflicts. However, the 

EMTs did indicate that the initial focus group done with them was good. They described it as “interactive” 

and an experience that dealt with them and the issues they face. They described the subsequent training as 

tedious and too long. In addition, they indicated being “inundated” with domestic violence trainings from 

various sources that were “not all on the same page.” They found this confusing and frustrating. 

How training helped. For both groups of physicians, heightened awareness of domestic violence 

was a key point from their training. Their comments included: “to even look for it;” “more prone to ask;” 

“ask all the time now;” “not feeling helpless—there’s something you can do—services and a legal record.” 

Another commented that he does a complete physical now in which the patient is entirely undressed in 

order to check for bruising. Physicians also reported awareness of the importance of documenting all their 

findings. “I try to document everything now.” They noted that documentation in general is heavily 

stressed by the attending physicians for fourth year residents. One commented that his legal 

documentation had improved, but the way he cared for his patients medically, or find resources has not 

changed. 

The nurses reported that they didn’t know the steps to go through with a DV case before the training. 

Now they have a clear set of procedures. Others reported that heightened awareness has made them screen 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 79

more. “My compliance with [the screening question] has increased. I used to ask sometimes, now I ask 

everyone....I’ve gotten a lot of ‘thank you for asking’ out there and that ...made me more aware of how 

important it is to ask.” “What you are telling the patient is we handle that sort of thing here, so if they have 

a friend....” 

Experiences and Difficulties in Documenting Domestic Violence 

Major Themes Across Provider Groups

Screening as a Documentation Issue

Screening for domestic violence was not a focus of the post-intervention focus groups. There were 

no questions about screening practices. In spite of this, screening and its related issues were mentioned 

frequently in these groups. The information is presented below. Clearly, screening and documentation are 

closely intertwined. Without screening there may not be appropriate documentation. One physician put it 

boldly: Discovery, not documentation, is the issue—“focus on how to teach emergency physicians how to 

screen better—We don’t ask and they don’t tell and they just get discharged.” 

One of the hospitals is emphasizing completion of the screening section on the triage forms. In 

addition, screening for DV is part of a “spot check tool,” and the nurses feel that will help them meet the 

goal of universal screening for DV. Some nurses respond to this and ask everyone. Others don’t 

necessarily do that. “I think we get a lot of those kind of patients (DV), but...we may miss a lot of 

them...if that’s not the reason they’re here.” One nurse noted seeing charts with questionable injuries, and 

no one had asked about domestic violence. 

 Both physicians and nurses run the gamut of whether and how frequently they screen for 

domestic violence. A couple of nurses reported asking everyone. “I ask everybody. I always say to 

people, ‘I don’t mean to be rude but we ask these questions to everyone.’” “My compliance with [the 

screening question] has increased. I used to ask sometimes, now I ask everyone....I’ve gotten a lot of 

‘thank you for asking’ out there and that ...made me more aware of how important it is to ask.” Others 

find it very difficult to ask about DV. “It’s hard to ask the question—it’s a private issue” “We don’t really 

screen too well.” Some physicians “rely on the nurses to let me know during their admission screening 

process.” Other physicians take the initiative more. “I find I ask a lot, lot more than I ever, ever did in the 

past and I think that if I didn’t train here where DV was a big issue I probably would never really have 

asked that much.” 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 80

 The majority of providers, however, ask if they suspect DV (bruises, story not making sense, vague 

complaints). Others note how easy it may be to miss DV cases, and try to be more alert to signs. “And 

how many of those are there out there that we totally and completely miss? And so I try to ask...anything 

that’s sort of just not right, ...like why does she have a ruptured TM?” 

Logistical problems in screening were mentioned by many of the nurses. It is hard to get the 

potential DV patient alone when the hospital has a policy that the family accompanies the patient. Some 

mentioned problems with getting appropriate interpreters and dealing with the family about interpreting if 

they suspect DV. One nurse noted that she tries to ask the screening question in triage because sometimes 

that is the moment they have them alone. However, most nurses felt that triage is not the place to ask 

about DV. They felt that you need more rapport to broach the subject, and that the primary nurse and/or 

doctor that will be taking care of them in the back is a better person to ask the question. One nurse was 

emphatic about this. “I have a history of this and I would definitely not have said yes to a 

stranger...never.....Not in a triage group, no.” Others commented: “...reality of expecting them to do it 

right off the bat doesn’t fit.....They’re gonna need to take some time, be treated, come into the system, I 

don’t think they want to admit to being...battered and sit in the waiting room for a few hours before you go 

see a doctor.” “It’s better for them if you get down to that later.” 

While most providers felt everyone should be screened, a number of them admitted to discomfort 

with asking about DV. Some just don’t feel comfortable talking about what is perceived as a private issue. 

One male noted, “I think I get a different look than a woman would get if she asked that question. That’s 

my perception.” In one physician group, only one of the four residents asks males about DV. In the other 

physician group, one physician only asked males if DV was suspected, whereas all females were asked as 

part of the history. 

All of the nurses in one group felt their screening question, “Are you safe at home?” is too vague and 

ambiguous. They wanted more specific questions—e.g., Is there anyone at home that is hurting you, 

threatening you, verbally putting you down, etc.? They felt they could miss DV cases by a question that 

could be interpreted as having to do with household safety instead of domestic violence. 

Three Inter-related Themes: Time, Medicine First, and “Not my expertise” 

The providers in emergency medicine mentioned three major inter-related themes fairly 

consistently—time pressures, a focus on “medical” over “social” issues, and discomfort with going outside 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 81

one’s area of expertise. Time constraints in the ER pressure providers to focus on medical issues, which is 

their area of expertise and first order of business. They are uncomfortable going outside their area of 

expertise because they don’t know what to do. They are unfamiliar with information about, resources for, 

and practices of domestic violence experts. Lack of familiarity means that anything they do will take more 

time than the DV experts doing the same thing—time they do not feel they have. They are also concerned 

that their ignorance, or relative lack of knowledge, may not help DV victims, and/or may inadvertently 

harm them. 

While all these themes are inhibitions to providers making changes in their documentation practices, 

in fact they are making changes, and they want to help in the ways they feel they are best suited for. They 

are willing to provide accurate documentation in the medical record, but would like more and regular 

training with examples of good and bad case records. A one to two hour, one time training session is not 

sufficient to change practices. They need “repetition and reinforcement.” They also want more materials 

as handouts and reminders of what to do when they identify a DV case. They want resources for 

themselves and their patients—e.g., in a resource book and on the computer. They emphasize that they 

need assistance from DV experts to deal with the more “social” aspects of domestic violence and to fill in 

the gaps of what they don’t know: taking complete histories, talking to the victims, providing support and 

access to resources, taking the time to follow-up the non-medical aspects of the DV case. 

Many providers appear to feel overwhelmed by the complexity of domestic violence cases in an 

environment in which they experience time pressures, lack DV knowledge and expertise, and in which 

their medical expertise addresses only one of the problems facing a DV victim. They talk as if they feel 

they are expected to deal with it all. In the absence of DV experts to assist in the cases, they do feel as if 

they are opening “Pandora’s box” (see quote below) when they encounter a domestic violence case. In 

addition, one nurse made reference to nurses’ need to “fix it.” “Once you ask the question and find out it’s 

DV, you have to have a plan. You can’t let it go, because then you’d be negligent—it’s a huge weight. 

But you can’t fix DV. It’s very frustrating to work with victims.” 

While the primary emphasis in the training is on appropriate documentation in the medical record, 

the nurses and physicians talked a lot about screening issues. It is in the screening, the necessary 

antecedent to documentation, that most of the following issues first emerged. 

Time Pressures in the ER. Time is a “huge factor” in the ER with domestic violence cases and was 

mentioned in all groups, except the EMTs. “Don’t tell me about DV—it takes too much time and I have 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 82

six other patients.” “When you’re the only nurse on and it’s busy...DV will take a back seat, there’s too 

much else to do.” “The training was great, but in reality I wouldn’t...I don’t have the time to do that. I 

would call the psych nurse.” “I’m screwed now. What have I done? Pandora’s box. I’ll never get out of 

this room. There’s a guy in 8 who needs to get discharged, the lady in 5 needs an IV, what is this woman 

gonna tell me?....” “Triage can’t do that [take time]. There’s six people screaming at you to get triaged 

before they can wait to see a doctor and so it’s like....” “We just don’t have the time.” 

The preceding comments were all from nurses. The physicians also mentioned time as a serious 

issue, but without concrete elaboration. Since nurses are the primary screeners for DV, either in triage, or 

“in the back” of the ER, they may experience the frenzy of time constraints in a much more concrete way. 

The EMTs did not mention the time factor in their discussion of difficulties with domestic violence cases. 

It may be that the structure of their work “on the street” is more elastic and responsive to the immediacy of 

what is going on—where they intervene, stabilize and transport to the ER—than would be the case in a 

hospital emergency room—where the cases pile up and have to be dealt with in varying levels of urgency. 

Or it may simply be that the other issues discussed by the EMTs were far more salient for them than time 

constraints. 

Focus on medical, not social issues. All provider groups mentioned the medical emphasis in their 

work. Essentially, they focus on and do what they were trained to do which is provide medical assistance 

in emergency settings. “We’re medical nurses, we’re not psych nurses, and we’re not denying the other 

side of it but we always see medicine as the first need and emotion as the second need.” “No problem 

documenting the physical things, but no time for the other stuff—send it on to psych to do and document—

they have all the resources and knowledge.” “You can handle the broken bones and the pain and the 

anxiety, and so forth...but I can’t handle all the social part of their problems.” “As an ER nurse, it’s not 

our real specialty. It’s nice to consult and move on....You probably have 5 other patients that are all 

different degrees of illness and although DV is very important, and it needs action, it’s just what you can 

do about it as an ER nurse is limited.” 

The EMTs’ focus is also medical, “not legal and allegations.” More than the physicians and nurses, 

they raised the issue of what you put in a medical document. As they put it, “who did it is for police to 

deal with.” “You’re more focused on when you go in what you see and think of the medical aspect of the 

record.” “...our primary focus is medicine, the provision of emergency medical services. Not to 

investigate legal statements or accusations that are made from one individual to another involved in a 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 83

domestic dispute....when you’re documenting, your primary concern is to document the injury or injuries, 

psychological state, if it’s pertinent to what’s going on with the individual.” Many EMTs perceived the 

documentation training as expecting them to focus on legal issues that they felt were in conflict with their 

EMT training. 

Discomfort with going outside one’s area of expertise. Providers often feel inadequate to deal 

appropriately with the DV cases. They feel they do not have the knowledge, expertise or ready access to 

resources to help their patients beyond their medical needs. Physicians said they can “discover” DV cases 

and treat the medical aspects, but they need DV experts to do the rest. They do not have the time or the 

expertise. 

Providers from the hospital without any DV team are emphatic about the need for DV experts to help 

them with their patients. Providers from the hospital that has a DV team are concerned about the lack of 

coverage during nights and weekends when they get a lot of the cases. Patients end up leaving or sitting in 

the ER all night. Sometimes they are put into a “safe bed.” 

Nurses without access to advocates said, “We definitely miss the advocates....they would help you 

and the patient and be in there for 45 minutes....they helped us do things we didn’t know how to do, and 

they did follow-ups.” “You don’t give me the tools to deal with domestic violence. You make me ask, 

you leave me hanging out there and my only resource is now a psych nurse who is stretched beyond belief 

some days with an entire psych suite full of patients and she’s also going to the term rooms dealing with 

families there.” In contrast, nurses with access to advocates noted the importance of being able to call in 

the DV team to deal with issues and resources that the nurses don’t know about. One nurse noted, 

“[We]...See the same people over and over again and after six or seven ‘I fell down the stairs’ or ‘I hit my 

head’...we would call the social worker to see the patient. They are better able to get the information out.” 

The EMTs had concerns about putting in the documentation “Injuries consistent with....” They 

perceived the documentation trainers wanted them to say this, but they only want to describe the injury and 

let someone else say what the injury is consistent with. They feel that is the job of the experts. The doctors 

and other experts should draw those conclusions. “...we’re not supposed to diagnose....this sounds like 

they’re asking us to diagnose the situation.” 

The EMTs also had concerns that naming names of who did what to whom makes the documentation 

a “legal document.” They felt police officers are required to name the names and are protected by law, but 

“there’s no DV law,” so they feel open to liability—“sort of puttin’ our asses out there in a sling, I hate to 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 84

tell you, because when you start writin’ people’s names and accusing them of stuff, that becomes a legal 

document.” They will record what people say, but they don’t want them to say too much because it may 

end up in court. They don’t want to name names. They want the police to put the names in. There was a 

heated discussion about this with some EMTs insisting that it was all right for them to write, “So and so 

states ‘John Smith’ hit her with a closed fist.” 

Sub-Themes 

EMTs’ Perceived conflict between medical training and documentation training. 

Many of the EMTs perceived a conflict between the EMS training and the domestic violence 

documentation training. “Some of the things they wanted you to write and we block those out. We said 

we can’t write those and they said, well you should write them and we said we can’t write those. Some of 

the instruction they gave us on how to document things were in total conflict with everything we’ve been 

taught throughout the years.” They described a “big debate” after the initial training, a “department-wide 

debate because everybody said you gotta listen to ‘em. And it became an issue. And I forget exactly what 

it was but it was this debate over, you know, we can’t be writin’ that because what we usually write is what 

we observe and not really like an opinion or to point fingers at a person on a sheet.” Not all the EMTs felt 

there was a conflict. What is clear is there is a great deal of confusion about what is expected with regard 

to documentation and whether the expectations are in conflict with their EMT training. There was 

discussion and disagreement about “pointing fingers” at someone. 

“...you go to a call and it’s he said, she said and finding out that it wasn’t him, it was someone else. 

So it just sort of made the ability to someone to stop pointing fingers at another person, whether they were 

right or wrong. And that was the way our documentation was supposed to be, observations, examinations, 

and we don’t write an opinion. We write, you know, what we observe, what we see, just the facts. And it 

became that, at the end of it, they wanted you to write an opinion and that became the issue.” Others 

disagreed. “I didn’t get it like that....thing they were saying is put patient alleges or patient states that X, 

Y, Z did this.” This group felt that the primary focus of the training is to document injuries so the medical 

record can support an investigation. 

Some EMTs don’t want to name people. They will write “husband,” “boyfriend,” but won’t name 

them. They feel it’s not their job. Others disagreed and said you are just saying what she said—you’re not 

saying it. You’re reporting her words—“You’re not liable for a statement that you record on behalf of an 

individual and I think that’s the key.” One EMT described giving a name and then the victim said, “no, not 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 85

that one.” There was clear concern that naming names makes it a “legal document.” They will record 

what people say, but don’t want them to say too much because it will end up in court—don’t name 

names—let the police put the names in. 

 Pointing fingers and naming names are clearly connected to concerns about retaliation. They 

are concerned for their safety in causing people legal problems. “You’re a witness.” “That’s not gonna 

stop us from goin’ to the call, it just happens to be that just now all of a sudden, you know...they 

remember you better than you rememberin’ them.” “Let the police be the ones that document....” Some 

clearly feel that extra info can come back to bite you, therefore you shouldn’t get it in the first place. There 

was much disagreement and discussion on this. Some were focusing on “it’s not my job,” while others 

wanted to help the DA by documenting. They wanted to get the guy off street. The abuser shouldn’t get 

away with the crime. 

What about men? 

The EMTs talked about encountering DV toward men and same gender DV, and noted the lack of 

training on those issues. “There’s somethin’ about when a woman kicks the crap out of a guy, and you say 

you know that asshole probably had it comin’ to him.[laughter]” “How often do you hear the term he 

probably deserved it? All the time.” “No, I hear she probably deserved it...” “NO!!!” “ I’ve heard it both 

ways.” 

“There’s a lot of same gender domestic violence that goes on because we have a very big gay 

community and there’s a lot of same gender and yeah, they’re right, there is nothing...I’ve never, ever sat 

in on any domestic violence thing where it said, you know anything about a guy kickin’ another guy’s butt 

or even a woman kickin’ a buy’s butt. It’s like the men are left out of the picture. They’re not...I mean 

like, what? So they don’t get hurt too?” 

Two of the six physicians noted they screened males for DV if they suspected something. Two of the 

nurses indicated they “asked everyone.” 

Priorities

One nurse brought up the issue of shifting priorities in the hospital, and questioned the hospital’s 

commitment to battered women at this point in time. In an earlier time physicians did safety plans for any 

physically injured woman. “She crushed her finger in the window, I want a plan of safety for her. You 

know, she stubbed her toe, I want a plan of safety for her, you know, and they did it. And [the director of 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 86

residency] harassed them for a while until it became routine and second nature and no big deal. And they 

can do that tomorrow.....the Director of Residency can say do this starting now and it’s done. Well, they 

don’t do it. You know, that doesn’t take a whole lot of implementation. That just shows attitudinal 

priority.” 

Frustration with victims reluctant to press charges 

A few nurses reported frustration with victims reluctant to make overt changes. “What’s frustrating 

is that if the patient doesn’t care themselves, then you feel like....What am I going to do? I’m going 

against a brick wall here.” Others pointed out the difficulty of “fixing” DV makes it frustrating to work 

with victims. You can’t fix it. You can only deal with the medical issues. 

An EMT reported frustration with a victim recanting and not pressing charges: 

“I’m going to court a week from today on a domestic violence case. The woman that’s involved, she 

gave me a lot of statements and I wrote everything she said. ...It’s not necessarily medicine, but I think 

it’s something the prosecution could use. She’s not gonna prosecute this guy cause two days later she’s 

gonna be back with the same guy just like she was the last time he beat her up. You know, it’s kind of 

frustrating for me to see it but she’s been beaten up by this guy a dozen times. ... my job, like I say, is 

medicine but she’s probably not gonna take the initiative to getting this guy off the street and I will.” 

Suggestions

Training. A number of providers suggested expanding training to other groups: medical schools, 

pediatrics for teenage relationship violence, psychiatric nurses, and other hospital staff—e.g., front desk, 

security, and secretaries. The physicians noted that as 4th year ER physicians they may be “secondary” on 

the chart documentation. “Primary” will be a younger non-ER resident who will be primarily responsible 

for documentation on the chart, and these residents have not had the documentation training. As the 

secondary physician, the ER resident will oversee what the other resident has done, but will not necessarily 

redo the documentation. They may only add a line or two. The 4th year ER residents felt that expanding 

the training to the other specialties would be helpful. 

All providers wanted further training and suggested annual refresher courses. They all found 

discussion groups focused around chart reviews, preferably with a lawyer, a very helpful format. They all 

also wanted concrete examples of what should and should not be written in a chart. What five or six things 

would further the case in court, and what things would keep documentation from helping a victim? 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 87

In general, some of the nurses indicated that education makes them more aware and more 

comfortable dealing with domestic violence cases. They specifically wanted training on the process the 

abused women go through in trying to end the abuse in their lives—“go over more of the steps... women 

have to go through before they finally leave....” In addition, they want training in how to talk to battered 

women—what to say that may help them “get out.” “We just have to be able to communicate....Each 

nurse should be educators in domestic violence and not leave it to the psych nurse.....without the talking 

there is not showing of caring and I think that these people need to be shown that someone cares. And 

you’re not going to show you care by stuffing a piece of paper in their hand. You do have to do that 

talking and that eye to eye....Training would help us try to get that across in a short amount of time.” 

One nurse suggested educating patients and professionals about the health issues of violence: “The 

hospital will hire people to teach diabetics how to take care of their toes. Well, they should. It’s very 

necessary if you have diabetes, you need a lot of education. But they won’t deal with the health issues for 

women being beaten. Well, if it’s a health issue, if you’re gonna teach about diabetes because it’s health, 

why don’t you teach about violence because it’s health?” 

Domestic Violence Experts. Physicians and nurses want 24 hour on-call DV experts to help them 

deal with the cases. It was one of the most consistently emphasized suggestions from these providers. If 

they lost the advocates, they want them back, and if they have them now during the day, they want them on 

nights and weekends. They clearly report that “discovering” DV cases without expert assistance to do 

those things the providers feel they don’t have time or expertise to do, leaves them feeling overwhelmed. 

Materials. There was a clear call for additional materials for both staff and patients. They want 

more visible, available information: posters, leaflets, and tear-offs, cards in the bathroom, a resource book, 

laminated cards—with information on the red flags of DV, what to document 1-10, phone numbers of 

resources, how to access DV experts. They also suggested putting this information on the website, so that 

everyone can access it—not just the ER—and so that information can be printed out for patients who may 

need it. 

Forms. Most providers reported that the existing forms had very little room to write. The space is 

too small to document what they need to. They would like more room and/or a different sheet of paper 

with more questions—like a check off to cue the interviewer about what to ask. 

Institutional priorities. In response to the question, “How can we better facilitate documentation?” 

One nurse suggested it had to be made an institutional priority. It is clear from many of the provider 

comments that they need institutional support in a variety of ways. Perhaps most emphatically, they want 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 88

on-call, or on-site access to DV advocates. They want to know it’s a priority for the institution by the 

provision of resources, by compensated training time, and by a clear mandate from administration that the 

institution is committed to screening for and documenting IPV. 

Break down barriers. Many of the EMTs felt the trainer really did not understand what their world 

was like and that created a barrier to good training. “They tell you what your job is and what to do and they 

have no idea what you’re going through.” Their solution to this lack of awareness was to “have them come 

ride with us.” “...You go out, you ride like in one of these trucks where they’re doing 15 calls a shift and 

they’re goin’ into some of the worst areas and going into some of the worst situations.” The trainers 

should then create a course guided by the EMTs’ needs on the street and then cover the legal aspects of it. 

Implications of the Findings for Further Interventions 

• Most of the providers want to help DV victims 

• They are, in fact, adjusting their documentation practices 

• They want help from DV experts in dealing with DV cases 

• They want further and ongoing training 

• They need clarification about what is and is not expected of them 

• They want to feel the trainer understands their particular work situation 

o They want training tailored to their needs 

• They want the commitment of the institution to the screening and documentation efforts 

It is important to emphasize that many providers feel that just doing their job, with the addition of 

asking about IPV, accurate documenting for IPV, and proffering referrals, is not perceived as enough, or 

even good medicine. They feel overwhelmed by the problem. For some reason they are not receiving the 

message of the training. The reasons for this may be complex, but it is clear that the tendency to try and “fix 

it” or to be focused on active problem solving, when all the battered woman wants is recognition, validation, 

getting her medical needs taken care of, and a possible referral, is getting in the way of providers adding a 

few small things to what they already do. The lack of institutional support appears to be a part of the 

problem, but a lack of understanding by providers about the complexity of making changes in the life of 

someone dealing with IPV may also contribute to unrealistic expectations of what they should do. One nurse 

explained that being educated about the process of change for abused women reduced her own frustration. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 89

They can’t fix it, but they can have a powerful impact just by doing their job with a modicum of sensitivity. 

They may not see the immediate result of what they do, but the impact on the lives of abused women is very 

real, as they themselves have said. 

Training for Advocates working in Health Care Settings 

In our proposal, we proposed to create and deliver a training to attorneys on how to use medical 

records in legal cases involving IPV. However, during the course of the project it became clear that it was 

too soon to try to predict with any certainty the reliability of the information that would be in the records. 

Rather than trying to reach attorneys we determined our time would be better spent presenting our findings 

and suggestions to advocates, social workers, and attorneys who attend IPV conferences. These advocates 

are more likely to work closely with patients and have access to patients’ attorneys including prosecutors 

and family law attorneys. They are also more likely to have contact with medical providers and know of 

the existence of documentation that could be used in court. Therefore, we increased chances of improving 

care to victims and informed use of records in health care through training advocates who regularly work 

with clients in health care settings. We sought to train advocates, social workers and attorneys in how to 

consider issues related to provider testimony, methods of record keeping that ensure patient privacy, and 

how medical records may be more useful to patients than social work or advocacy records. Advocates and 

social workers working in these settings are also more likely to have regular contact with providers and 

may have the most access to and influence on providers with regard to changing their attitudes about 

working with clients. One on one training through advocates may be the best way to create change and 

change the culture of medical settings rather than department wide training. Also, attorneys are more 

likely to track down the advocate or social worker if there is a need for evidence. Training advocates and 

social workers how to work with attorneys and how to assist the relationship between doctor and attorney 

is helpful in increasing the amount of medical testimony and evidence introduced into legal settings. 

Finally, if an attorney is not incorporating the medical treatment history or health impacts of abuse suffered 

by a woman, the advocate or social worker can empower the client to raise these issues or contact the 

attorney to tell them what kind of information exists and how it could be helpful, particularly for those 

attorneys who do not regularly represent victims of IPV. 

Fortunately, The Family Violence Prevention Fund sponsored Jane Doe, Inc, to conduct a statewide 

project as part of a national campaign to address health care response to IPV. This project is called “The 

Massachusetts Statewide Healthcare Awareness, Response, Resources and Education on Domestic 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 90

Violence (SHARED) Project and is directed by Liza Sirota White. The PI actively participated in one 

aspect of this project that examined issues related to documentation, privilege and confidentiality. 

Comparing the roles and responsibilities of the various providers working in different health care settings 

and making recommendations related to documentation for each was one focus of this project. A 

presentation developed for two national conferences and three regional domestic violence advocacy 

conferences is contained in the Appendix. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 91

Lessons Learned & Recommendations 

Several valuable lessons emerged over the course of this project. We have selected several lessons to share 

and made recommendations for future work and replication efforts. 

Lesson One: 

Most providers easily recognize physical symptoms related to IPV. Providers 

struggle with how to talk to patients who disclose abuse and how to deal with 

patients who present with symptoms but do not disclose abuse. Providers may 

become so focused on avoiding IPV or investigating it that they run out of time 

to do what they are most qualified to do: assessing, treating or documenting 

the patient’s medical needs. 

Recommendations: 

 Providers need direction in how to talk to patients about abuse, the 

impacts of abuse on the patients’ health and how to limit the scope of 

inquiry so that they can attend to medical needs. 

 Providers need to remember to conduct thorough assessments of past, 

potential and current injures, treat all injuries and better document 

observations rather than focusing all their attention on collecting details 

of an incident, safety planning or referring patients to IPV services. 

 Providers must understand that it is not their responsibility to ‘make a 

patient safe’ or solve her problems. Providers can play an important 

role by educating patients that help and resources are available, 

breaking patients’ isolation, build patients’ trust in helping systems and 

creating a positive help-seeking experience.

 Providers need more training in how to recognize psychological and 

emotional abuse and how this type of abuse impacts a patient’s 

physical and mental health and her ability to manage health care issues.

Lesson Two: 

The feasibility of implementing an IPV protocol, delivering training related to 

the protocol and evaluating provider adherence to the protocol is dependent 

upon adequate resources and department-wide support. 

Recommendations: 

 Department resources must be carefully evaluated in order to assess the 

best means of implementing an IPV response. 

 To maximize limited training resources, training sessions should be 

offered to as many providers as possible at the same time. However, 

obtaining full department participation may require offering several 

trainings at varying times to accommodate provider work schedules. 

Significantly more resources are necessary to implement a protocol in a 

24-hour setting than one that operates during regular business hours. 

 Administrative support for participation in trainings and implementing 

protocol practices in the form of monetary compensation and 

professional recognition would greatly enhance training participation 

and protocol implementation. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 92

Lesson Three: 

Implementing a team approach to respond to IPV in health care settings 

enables providers to use their medical skills to support victims and do so 

within their time and resource constraints. 

Recommendations: 

 Providers should provide a limited intervention that includes: 

 Inquiring in a kind and private way about symptoms or 

presentations that raise a concern of IPV; 

 Performing a careful assessment of all symptoms and 

conditions not just the most serious injury; 

 Inquiry into the healing of past injuries 

 Treating all medical conditions; 

 Documenting any patients descriptions of incidents of abuse 

resulting in need for medical care including facts relating to 

who, what, where, when, how, type of force and any weapons 

used. Quotes and “patient reports” is the recommended means 

of documenting the patient’s description of events. 

 Documenting injuries and health conditions in a detailed and 

specific manner. Providers may have to draw their own body 

maps. Photographs are recommended if they will be sufficiently 

protected and stored with the medical record or given to the 

patient or patient advocate. 

 Counseling, safety planning and advocacy work should only be 

performed by providers or others who have received extensive formal 

training in IPV. 

 Providers need to plan for patient and provider safety during patient’s 

stay in the institution. Providers should involve security personnel in 

safety planning rather than waiting until a problem arises. 

 Providers can indicate to patients that help is available, that change is 

possible and offer resource numbers and referrals to IPV services in a 

five-minute intervention. 

Lesson Four: 

Many providers feel that they do not have the time or resources within the 

treatment setting to solve the problem of IPV. Most providers only consider a 

response effective if it achieves patient safety upon discharge. Such high 

expectations are unrealistic given the complicated nature of IPV. 

Recommendations: 

 Modifying expectations to create more realistic goals to achieve an 

effective response to IPV is necessary. 

 A team approach to IPV in health care settings will optimize limited 

resources. 

 Providers who conceptualize themselves as a part of a team of service 

providers are more likely to see the potential for successfully 

responding to IPV.

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 93

Lesson Five: 

General Protocols developed by organizations or outside health care 

institutions serve as useful templates for devising a protocol but it must be 

tailored to meet the circumstances, needs and resources of each particular 

setting. 

Recommendations: 

 A thorough exploration of current workings and procedures, including 

forms and electronic record keeping systems, must inform any protocol 

related to IPV. 

 Providers with extensive experience working in the setting are vital to 

the development of a working protocol. 

 Patients should also be consulted for recommended responses. 

 Relevant administrative offices including legal counsel, social work 

and medical records departments should be involved in developing the 

protocol. 

 Protocols should incorporate local resources.

Lesson Six: 

Medical documentation is not necessarily standardized among providers, even 

within the same department. Many medical record forms are not user friendly 

in cases of IPV and do not provide for photograph storage. 

Recommendations: 

 Standardizing documentation methods would improve patient records 

by clarifying what occurred at each visit. 

 More consistent documentation strategies could only increase the 

quality and continuity of care. 

 Providers within departments or institutions should adopt a list of 

abbreviations that everyone could use. A legend depicting commonly 

used abbreviations would greatly increase the likelihood that records 

could be introduced into court without requiring that a provider 

interpret the records. 

 Medical record forms should be constructed to make response to IPV 

easier to document. A storage place for photographs and releases 

should be provided.

 Providers should be informed of rules governing their release of 

information related to patient treatment. Providers should also be 

familiar with rules and procedures relating to how their health care 

institution manages and protects patient records. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 94

Lesson Seven: 

Many of the providers involved in the study believe that if an IPV intervention 

cannot be executed fully from beginning to end with a patient, the provider 

should avoid the issue of IPV altogether. Many of the IPV training manuals 

and protocols may inadvertently reinforce this message. 

Recommendations: 

 It is better for providers to perform one step of an intervention than do 

none at all. Simply acknowledging abuse is important. 

 Most patients are not expecting and may not want extensive services 

from a health care setting. Perhaps only certain aspects of an 

intervention will suit a patient’s needs. Responding to each patient’s 

unique circumstances is likely to encourage her or him to seek help 

again in the future. 

 The quickest and easiest intervention for providers is to leave a card 

with resource numbers in a place where patients can review them in 

private and take them home without notifying hospital staff. Many 

patients prefer to receive resource numbers in this private manner. 

 Most areas have a 24-hour hotline that IPV victims can call 

anonymously to talk to a trained IPV counselor. Providers without the 

time or skills to address IPV should provide patients access to a phone 

in a private room so they have an opportunity to make this call.

Lesson Eight: 

A 50-minute training to a portion of the staff is not enough training to create 

significant change in how a medical site addresses IPV. Additional training 

time would better able trainers to address training priorities more fully. 

Recommendations: 

 Providers would be more likely to adopt practices if all providers were 

required to attend training, incentives to acquiring knowledge and skills 

were made available, and structural changes to procedures and medical 

records could be made to accommodate provider concerns. 

 Training needs to be on-going and conditions that reinforce 

implementing knowledge and skills into practice needs to be 

established. Further study and thought should be given to training 

methods other than in-service group sessions. Alternatives could 

include: 

 Small group record reviews 

 One-on-One clinical consultations during work shifts 

 Partnering with a domestic violence advocate to deliver services 

on a case-by-case basis 

 Training should be delivered to all staff, and it may be more effective 

to train across provider groups, preferably training providers who 

regularly work together as a team. 

 Future studies should incorporate mechanisms to ensure maximum 

feedback from study participants as to usefulness of the training after 

some period of implementing intervention strategies. 

 Further study of how to sustain effects of training and to continue to 

improve documentation processes is needed.

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 95

Conclusion 

The Need for Institutional Support in Addressing IPV. Many helpful protocols, guidelines and 

training manuals are available to assist health care providers to develop more effective strategies for 

addressing IPV. Resources have been tailored to address different types of practice settings and the 

varying roles played by different types of providers. However, despite the tremendous effort devoted to 

improve health care response to IPV, current practice in most medical settings need to undergo significant 

changes in order to confront the health impacts of IPV through consistent identification, careful 

assessment, and comprehensive treatment of injuries and health related symptoms that result from IPV. 

A review of this report and any protocol, guidelines or training manual addressing health care 

response to IPV reveals that providers are being asked to make substantial changes in the way they 

currently address patients presenting with IPV. Many providers, like professionals in so many other 

disciplines, did not choose to specialize in IPV work but instead have been thrust into it as a result of their 

chosen area of interest whether it is medicine, law, social work, or psychiatry. While they may prefer to 

avoid issues such as IPV, child abuse and neglect, elder abuse and other violent crimes it will inevitably be 

a part of their work. Accordingly, if providers are expected to adopt new approaches and implement them 

into their every day practice, they must be given adequate resources, support and training. In order to 

effect changes in provider behavior, institutions must recognize the needs of providers, develop approaches 

and practices that make sense within each treatment setting, and make structural and institutional changes 

to support recommended practices. 

First, health care administrators who control budget decisions must also recognize how regularly 

providers may see patients experiencing IPV and acknowledge the resources necessary to properly respond 

to this problem. Resources include ongoing clinical training, access to private treatment rooms in a 

secured area, working partnerships with other relevant services within the health care setting (security, 

social work, IPV advocates, interpreters) and referral mechanisms to services outside the health care 

setting (IPV support groups, safe housing, police and legal advocacy programs.) 

Next, institutions must coordinate designated persons from relevant departments within the institution 

to design a response to IPV for various departments that best suits the needs, circumstances and resources of 

each department. Creating an interdisciplinary working team made up of health care providers delivering 

direct services, legal counsel, risk managers, and medical records staff will increase the likelihood of 

devising a response that will work and protect providers and the institution from any liability or unnecessary 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 96

costs. (Brouhard & Mahoney, 2002) When developing a response, institutions must also consider creating 

partnerships with services outside of the hospital in order to supplement their own resources. 

Finally, the institution must implement the plan through infusing money and personnel resources 

where appropriate, making structural and systems modifications where necessary, working with providers 

to acquire the skills necessary to incorporate the IPV response into their practice and maintaining positive 

relationships with service partners outside the hospital. 

When developing an IPV response institutions can help by creating attainable goals that emphasize 

skills commonly associated with health care delivery. Seen as a part of managing health care, providers 

can begin to view IPV as a problem that is solved over time rather than overnight and see themselves as 

one helper among many rather than a lone problem solver. A change in expectations can help providers to 

see the potential for success in their interactions with IPV patients. Providers often complain that it is 

difficult to help IPV victims because they view patients as, “unwilling to help themselves by taking action 

to leave the abusive partner.” Expecting to effectuate drastic life changes in patients’ lives in one 

treatment visit is unrealistic and typically results in providers and patients feeling disappointed and 

frustrated. 

A Shift in Perspective. One of the most common misconceptions about IPV by many providers is 

that the problem should and can be solved immediately. This is especially true in certain health care 

settings such as the emergency setting. The truth is that with the exception of a few cases, most victims 

need time to end the IPV in their lives. IPV relationships rarely are ended quickly and simply. For this 

reason, providers need to shift their goal away from fixing a patient’s problem or making the patient safe. 

Instead providers need to support a patient’s effort to seek help and at the same time address her health 

needs and record observations. These behaviors are well-within the provider’s expertise and help the 

patient in ways that can extend long past the visit. Documentation of a thorough assessment of injuries 

caused by IPV is a good example of important work that providers can do to assist patients. 

Providers understanding how they can play a role in the larger scheme of IPV service delivery 

enables them to contribute their expertise to patients’ problem solving, even if resolution of the problems 

occur sometime in the future. Providers may not see the beneficial outcomes of their work, but will know 

that by maintaining good treatment records, they afford patients what may be the only third party record of 

symptoms and injuries resulting from abuse. As such, these records can be vital in assisting patients to 

gain independence from their abusive partners. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 97

Providers’ experiences with IPV will be more rewarding and less frustrating if realistic expectations 

are set, adequate resources to accomplish goals are available, and providers learn to coordinate their work 

with other services providers in and outside the hospital. 

Interdisciplinary and Institutional Collaboration. This evaluation project exists due to the 

working relationship built among research team members over several years. These relationships were 

built in the context of providing direct services to IPV victims in legal, shelter and health care settings. To 

improve services to clients, we forged new working relationships across institutions and disciplines. Such 

experiences taught us that sharing different areas of expertise, skills, access to resources and perspectives 

could only benefit each of our individual clients. Working cooperatively enabled us to spend more time 

with each client and turn fewer clients away. Each of us was released from the untenable task of being 

everything to every client and instead only responsible to deliver services within our skill and knowledge 

base. We provided services that were best suited to our professional role and referred clients to other 

services we knew well and to providers whom we trusted. Working across agencies and disciplines 

resulted in breaking the isolation that is so often associated with IPV service delivery in any professional 

setting. Surely, there are success stories of similar interdisciplinary working teams in other health care 

settings. However, this model has yet to be implemented completely enough to accurately assess its 

effectiveness. 

Interdisciplinary working may not guarantee success in every case but it improves the likelihood of 

accomplishing small successes that may pave the way to patients’ future safety. Supporting providers in 

each setting to implement a team-based approach and to build interdisciplinary working relationships 

increases the chances that change will occur on a level that will eventually change the culture of resistance 

that currently exists in many health care settings. Over time, implementing a consistent response to IPV 

will result in improved health care, increased satisfaction by providers who work with IPV victims and 

substantial economic savings to health care institutions. 

Future Research. Further study is needed to explore what strategies will increase institutional and 

administration’s investment and support of a consistent and effective IPV response in health care settings. 

Our project revealed that many providers have not been exposed to the wealth of knowledge and IPV 

resources developed over the past two decades. Even those providers who have been exposed to some 

information related to IPV have not had adequate incentive or support to incorporate this knowledge into 

their practice on a consistent basis. Lack of time was a serious concern for all participants in the study. 

Effective training and skills development to deliver health care that effectively responds to IPV takes time. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 98

Additional research exploring different methods of disseminating information, incentive for acquiring 

increased knowledge, and identifying time efficient means of developing providers’ skills is much needed. 

A useful area of study would be a more in-depth examination of what changes would need to be made so 

that IPV education and clinical training were required course work in medical, nursing and EMT schools. 

A critical look at how implementation of an IPV protocol on an institution wide basis may effect or 

transform the culture of the setting as opposed to training specific providers or individual departments 

would also add to current knowledge. 

This document is a research report submitted to the U.S. Department of Justice. This report has not 

been published by the Department. Opinions or points of view expressed are those of the author(s) 

and do not necessarily reflect the official position or policies of the U.S. Department of Justice. 
Enos, et al, “An Intervention to Improve Documentation of Intimate Partner Violence in Medical Records” 99

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