One of the most important things a clinician can do to help an abused woman is to document everything. Take a detailed history of the pattern of abuse. Injuries from violent acts can range from minor bruises to deep cuts and lacerations, internal wounds, neurologic trauma, and death. All observed and reported signs or symptoms of physical, psychological, or sexual abuse should be recorded in the client's chart. Use a body map, diagram or photographs to record the details of the injury.
Many state laws require the victim to sign a permission form before an X-ray or photograph is taken.
When taking photographs, we suggest you follow the AMA-recommended procedures listed below. Use color film. Take two photographs of every area of injury. Use a ruler or other identifiable object to illustrate the size of each injury. Include the patient's face in at least one picture.