Activity | Initial Visit
(Physician and nurse do physical and mental health assessment and treatment; social
Worker or IPV Advocate/Nurse does social assessment and treatment) |
Physical Assessment and Treatment | Presenting Complaint:
- Assess trauma.
- Document with body map/photos and description.
- Refer or treat as appropriate.
- Report to police if gunshot or knife wound or according to State law.
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Physical Assessment and Treatment | Sexual Trauma:
- Ask about forced or undesired sex.
- If NO: document only.
If YES and not IPV RAPE: examine for injuries, treat, refer, document. Discuss
contraceptive options, prevent pregnancy and STDs.
If YES and IPV RAPE (within last 72 hours do pelvic exam, evidence collection);
examine for injuries, treat, refer, document. OFFER pregnancy test and STD/HIV test.
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Physical Assessment and Treatment | Pain:
- Assess site, type, severity, and duration.
- If NO: document only.
If YES: assess pain in relation to violence history and its possible influence on
sign/symptoms/illnesses, especially: Neurological, GI/Abdominal, GYN, Chronic
stress, Other. Document, refer and/or treat.
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Psychiatric/Mental Health Assessment and Treatment | Substance Abuse:
- Screen for current substance abuse problems of patient and abuser.
- If NO: document.
If YES: inform of treatment options and refer if interested at this time. Document.
- Reinforce that this is a separate health problem from IPV although it may be exacerbated by or exacerbate IPV.
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Psychiatric/Mental Health Assessment and Treatment | Depression:
- Assess symptoms of depression, severity and duration and relationship to IPV history.
- Assess client's need for medication. If appropriate, prescribe psychotropic medication and/or refer for psychiatric services or counseling.
- Using danger assessment guidelinesa assess for: suicide/homicide potential or attempts. If YES, refer for psychiatric consult. Document. Review legal protections available for homicide prevention.
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Psychiatric/Mental Health Assessment and Treatment | PTSD/Anxiety:
- Assess sleep, startle, anxiety, re-experiencing of trauma (flashback), numbing.
- If YES, refer for psychiatric consult.
|
Social Assessment and Treatment |
IPV Services:
- IPV counselor meets with patient.
- Assess trauma history.
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Social Assessment and Treatment | Additional Demographics:
- Marital status with abuser: married, separated, divorced, widow, single.
- Living with abuser: yes, no, sometimes.
- Harassment and/or stalking by abuser?
- Children: number and ages. Custody?
- Health insurance: none, abuser's policy, personal policy.
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Social Assessment and Treatment | Information on Children:
- During woman's treatment/hospitalization: children living with patient? Where are they now? How can their safety and care be assured? How support mother's custody?
- Child trauma: ask if children demonstrating signs of trauma from observing violence (i.e., sleep problems, nightmares, aggressiveness or withdrawal, school problems). Refer if indicated.
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Social Assessment and Treatment | Danger:
- Use Danger Assessment guidelinesa to assess IPV severity and extent of danger. Express concern for safety.
- Explain police services. Ask if victim desires for provider to call police.
- Explain court ex parte/protection orders and victim's services and legal assistance options. Give resource sheet.
- Explain mandatory legal reporting of child abuse. Inquire if children have been abused and refer if indicated.
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Social Assessment and Treatment | Safety Planning:
- Use guidelinesb to assess safety behaviors and plans for future.
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