The medical record can serve as compelling evidence in legal proceedings including criminal prosecution, child custody, and other civil matters. Complete and accurate data will help advocacy efforts to increase funding for shelters and other services and encourage local, state, and federal agencies to adopt effective public policies. Reimbursement for medical services is often tied to coding. Victims of domestic violence may need services beyond the treatment of physical injuries including risk assessment, counseling, and other services. Proper coding and documentation can facilitate reimbursement for much needed additional services.
Proper documentation protects providers against liability.
Insurance companies, the Medicaid system, and HMO's are primarily data driven. It is necessary to document the need in order to justify enhanced services and the allocation of resources. While documenting domestic violence is crucial for these reasons, improper disclosure of health information can pose serious safety, discrimination and emotional risks to the patient.