Responses to intimate partner victims are most efficient and effective when coordinated in a multi-disciplinary manner and in collaboration with domestic violence (DV) advocates so that no single provider is responsible for the entire intervention. All providers in the settings listed in the original guideline document should be trained and achieve basic competence regarding how to identify and respond to intimate partner violence (IPV). Site-specific policies should be developed that clarify each provider's role in implementing specific elements of the protocol.
Inquiry
What should providers ask?
Ask patients about current and lifetime* exposure to IPV victimization, including direct questions about physical, emotional, and sexual abuse.
*Because of the long-term impact of abuse on a patient's health, we recommend integrating assessment for current and lifetime exposure into routine care. However, we acknowledge there will be times (particularly in emergency/urgent care) when assessment for lifetime exposure to abuse will not always be possible due to time constraints.
Who should be routinely asked about current and past IPV victimization?
- All adolescent and adult patients* regardless of cultural background
- Parents or caregivers of children in pediatric care
(Please see Appendix A and Appendix B in the original guideline document for setting-specific recommendations and for recommendations in child health settings, respectively).
*The majority of IPV perpetrators are male, so assessing all patients increases the likelihood of identifying perpetrators for victimization. We recommend routinely assessing men only if additional precautions can be taken to protect victims whose batterers claim to be abused. Training providers on perpetrator dynamics and the responses to lesbian, gay, transgender, bisexual, and heterosexual victims is critical, regardless of policies to assess all patients or women only.
(See Appendix C in the original guideline document for recommendations on assessing all patients for IPV).
How should inquiry for present and past IPV victimization occur?
Assessment should be:
- Conducted routinely, regardless of the presence or absence of indicators of abuse
- Conducted orally as part of a face-to-face health care encounter
- Included in written or computer based health questionnaires
- Direct and nonjudgmental using language that is culturally/linguistically appropriate
- Conducted in private: no friends, relatives (except children under 3), or caregivers should be present
- Confidential: prior to inquiry, patients should be informed of any reporting requirements or other limits to provider/patient confidentiality
- Assisted, if needed, by interpreters who have been trained to ask about abuse and who do not know the patient or the patient's partner, caregiver, friends, or family socially
When should inquiry for past and present IPV victimization occur?
- As part of the routine health history (e.g., social history/review of systems)
- As part of the standard health assessment (or at every encounter in urgent care)
- During every new patient encounter
- During periodic comprehensive health visits (assess for current IPV victimization only)
- During a visit for a new chief complaint (assess for current IPV victimization only)
- At every new intimate relationship (assess for current IPV victimization only)
- When signs and symptoms raise concerns or at other times at the provider's discretion
(Please see Appendix D in the original guideline document for suggested assessment questions and strategies).
When should inquiry not occur?
- If provider can not secure a private space in which to conduct inquiry
- If there are concerns that assessing the patient is unsafe for either patient or provider
- If provider is unable to secure an appropriate interpreter
If inquiry does not occur:
- Note in chart that inquiry was not completed and schedule a follow-up appointment (or if in an urgent care setting, refer patient to a primary care provider)
- Have posters, safety cards, and patient education materials about IPV available in exam or waiting rooms, bathrooms, or on discharge instructions
Health and Safety Assessment
The goals of the assessment are to a) create a supportive environment in which the patient can discuss the abuse and b) enable the provider to gather information about health problems associated with the abuse and c) assess the immediate and long-term health and safety needs for the patient in order to develop and implement a response.
When should assessment occur?
- Initial assessment should occur immediately after disclosure.
- Repeat and/or expanded assessments should occur during follow-up appointments.
- At least one follow-up appointment (or referral) should be offered after disclosure of current or past abuse with health care provider, social worker, or DV advocate.
What should assessment include?
For the patient who discloses current abuse, assessment should include at a minimum:
Assessment of immediate safety
- "Are you in immediate danger?"
- "Is your partner at the health facility now?"
- "Do you want to (or have to) go home with your partner?"
- "Do you have somewhere safe to go?"
- "Have there been threats or direct abuse of the children (if s/he has children)?"
- "Are you afraid your life may be in danger?"
- "Has the violence gotten worse or is it getting scarier? Is it happening more often?"
- "Has your partner used weapons, alcohol or drugs?"
- "Has your partner ever held you or your children against your will?"
- "Does your partner ever watch you closely, follow you, or stalk you?"
- "Has your partner ever threatened to kill you, him/herself, or your children?"
If the patient states that there has been an escalation in the frequency and/or severity of violence, that weapons have been used, or that there has been hostage taking, stalking, homicide or suicide threats, providers should conduct a homicide/suicide assessment.
(See Appendix E in the original guideline document for danger assessment and other assessment tools).
Assess the impact of the IPV (past or present) on the patient's health:
There are common health problems associated with current or past IPV victimization. Disclosure should prompt providers to consider these health care risks and assess:
- How the (current or past) IPV victimization affects the presenting health issue
- "Does your partner control you access to health care or how you care for yourself?"
- How the (current or past) IPV victimization relates to other associated health issues
(See Appendix F in the original guideline document for expanded assessment areas).
Assessment of the pattern and history of current abuse:
- "How long has the violence been going on?"
- "Have you ever been hospitalized because of the abuse?"
- "Can you tell me about your most serious event?"
- "Has your partner forced you to have sex, hurt you sexually, or forced you into sexual acts that made you uncomfortable?"
- "Have other family members, children, or pets been hurt by your partner?"
- "Does your partner control your activities, money, or children?"
For the patient that discloses past history of IPV victimization:
- "When did the abuse occur?"
- "Do you feel you are still at risk?"
- "Are you in contact with your ex-partner?" "Do you share children or custody?"
- "How do you think the abuse has affected you emotionally and physically?"
What to do if a patient says "no":
- Respect her/his response.
- Let the patient know that you are available should the situation ever change.
- Assess again at previously recommended intervals.
- If patient says "no" but you believe s/he may be at risk, discuss the specific risk factors and offer information and resources in exam and waiting rooms, or bathrooms.
(See Appendix G in the original guideline document for indicators of abuse that should prompt follow-up questions).
Interventions with Victims of IPV
Interventions will vary based on the severity of the abuse, the patient's decisions about what s/he wants for assistance at that time, and if the abuse is happening currently. It is important to let the patient know that you will help regardless of whether s/he decides to stay in or leave the abusive relationship. For all patients who disclose current abuse providers should:
Provide validation:
- Listen non-judgmentally.
- "I am concerned for your safety (and the safety of your children)."
- "You are not alone and help is available."
- "You don't deserve the abuse and it is not your fault."
- "Stopping the abuse is the responsibility of your partner, not you."
Provide information:
- "Domestic violence is common and happens in all kinds of relationships."
- "Violence tends to continue and often becomes more frequent and severe."
- "Abuse can impact your health in many ways."
- "You are not to blame, but exposure to violence in the home can emotionally and physically hurt your children or other dependent loved ones."
Respond to safety issues:
Offer the patient a brochure about safety planning and go over it with her/him.
(Please see Appendix H in the original guideline document for a sample safety plan).
- Review ideas about keeping information private and safe from the abuser.
- Offer the patient immediate and private access to an advocate in person or via phone.
- Offer to have a provider or advocate discuss safety then or at a later appointment.
- If the patient wants immediate police assistance, offer to place the call.
- Reinforce the patient's autonomy in making decisions regarding her/his safety.
- If there is significant risk of suicide, the patient should be kept safe in the health setting until emergency psychiatric evaluation can be obtained.
Make referrals to local resources:
- Describe any advocacy and support systems within the health care setting.
- Refer patient to advocacy and support services within the community.
- Refer patients to organizations that address their unique needs such as organizations with multiple language capacities, or those that specialize in working with specific populations (i.e., teen, elderly, disabled, deaf or hard of hearing, particular ethnic or cultural communities, or lesbian, gay, transgender, or bisexual clients)
- Offer a choice of available referrals including on-site advocates, social workers, local DV resources, or the National DV Hotline (800) 799-SAFE, TTY (800) 787-3224
For the patient who discloses past but not current IPV victimization:
- "Domestic violence is common and happens in all kinds of relationships."
- "Abuse can impact your health in many ways."
- "What happened to you may be related to health problems now."
- "How do you feel about this now? Is there anything I can do for you now?"
- If the patient feels the issue is still affecting them physically or emotionally, offer to set up an appointment to discuss it further with a primary care provider, mental health provider, social worker, or DV advocate, depending on the patient's needs.
(Please see Appendix I in the original guideline document for more detailed recommendations on interventions for patients with current and/or past experience with IPV).
Reporting IPV to law enforcement or social service agencies:
Some states have requirements to report current victimization to law enforcement or social services. Providers should:
- Learn applicable statutes in your state (See Appendix J in the original guideline document for a summary of state laws).
- If you practice in a state with a mandated reporting law, inform patients about any limits of confidentiality prior to conducting assessment.
(See Appendix B in the original guideline document for a discussion of reporting requirements for child exposure to IPV).
Confidentiality procedures:
Inappropriate disclosure of health information may violate patient/provider confidentiality and threaten patient safety. Perpetrators who discover that a victim has sought care may retaliate with further violence. Employers, insurers, law enforcement agencies, and community members who discover abuse may discriminate against a victim or alert the perpetrator. It is imperative that policy, protocol, and practice surrounding the use and disclosure of health information regarding victims of IPV should respect patient confidentiality and autonomy and serve to improve the safety and health status of victims of IPV. The federal medical records privacy regulations issued in August 2002 (in effect April 14, 2003) have specific implications for victims of violence.
Prior to implementing a domestic violence program:
- Review relevant state privacy laws.
- Follow the federal regulations and privacy principles for victims of IPV.
(For a summary of new federal regulations, see Appendix L in the original guideline document).
Documentation
Documentation should be conducted by a health care provider who is authorized to record in the patient's medical record. Providers should document the patient's statements and avoid pejorative or judgmental documentation (e.g. write "patient declines services" rather than "patient refuses services," "patient states" rather than "patient alleges").
(See Appendix B in the original guideline document for recommendations on documentation in child health settings).
Document relevant history:
- Chief complaint or history of present illness
- Record details of the abuse and its relationship to the presenting problem.
- Document any concurrent medical problems that may be related to the abuse.
- For current IPV victims, document a summary of past and current abuse including:
- Social history, including relationship to abuser and abusers name if possible
- Patient's statement about what happened, not what lead up to the abuse (e.g., "boyfriend John Smith hit me in the face," not "patient arguing over money")
- Include the date, time, and location of incidents where possible.
- Patient's appearance and demeanor (e.g., "tearful, shirt ripped," not "distraught")
- Any objects or weapons used in an assault (e.g., knife, iron, closed or open fist)
- Patient's accounts of any threats made or other psychological abuse
- Names or descriptions of any witnesses to the abuse
Document results of physical examination:
- Findings related to IPV, neurological, gynecological, mental status exam if indicated
- If there are injuries, (present or past) describe type, color, texture, size, and location.
- Use a body map and/or photographs to supplement written description.
- Obtain a consent form prior to photographing patient. Include a label and date.
(See Appendix K in the original guideline document for more on photo documentation and forensic evidence collection).
Document laboratory and other diagnostic procedures:
- Record the results of any lab tests, x-rays, or other diagnostic procedures and their relationship to the current or past abuse.
Document results of assessment, intervention, and referral:
- Record information pertaining to the patient's health and safety assessment including your assessment of potential for serious harm, suicide, and health impact of IPV.
- Document referrals made and options discussed.
- Document follow-up arrangements.
If patient does not disclose IPV victimization:
- Document that assessment was conducted and that the patient did not disclose abuse.
- If you suspect abuse, document your reasons for concerns (i.e., "physical findings are not congruent with history or description," "patient presents with indications of abuse.")
Follow-Up and Continuity of Care for Victims
At least one follow-up appointment (or referral) with a health care provider, social worker, or DV advocate should be offered after disclosure of current or past abuse:
- "If you like, we can set up a follow-up appointment (or referral) to discuss this further."
- "Is there a number or address that is safe to use to contact you?"
- "Are there days/hours when we can reach you alone?"
- "Is it safe for us to make an appointment reminder call?"
At every follow up visit with patients currently in abusive relationships:
- Review the medical record and ask about current and past episodes of IPV.
- Communicate concern and assess both safety and coping or survival strategies:
- "I am still concerned for your health and safety."
- "Have you sought counseling, a support group, or other assistance?"
- "Has there been any escalation in the severity or frequency of the abuse?"
- "Have you developed or used a safety plan?"
- "Told any family or friends about the abuse?"
- "Have you talked with your children about the abuse and what to do to stay safe?"
- Reiterate options to the patient (individual safety planning, talking with friends or family, advocacy services and support groups, transitional/temporary housing, etc.)
For current and previous victims of IPV:
- Ensure that patient has a connection to a primary care provider.
- Coordinate and monitor an integrated care plan with community-based experts as needed, or other health care specialists, trained social workers, or mental health care providers as needed.
(For more information on addressing short and long term mental health effects of IPV victims see the American Medical Association's [AMA's] Diagnostic and Treatment Guidelines on Mental Health Effects of Family Violence referenced in Appendix N of the original guideline document).
If patient does not disclose current or past IPV victimization:
- Document that assessment was conducted and that the patient did not disclose abuse.
- If you suspect abuse, document your reasons for concern (i.e., "physical findings are not congruent w/ history or description," "patient presents with indicators of violence.")
