Health care professionals are often the first, and perhaps the only, professional a victim will turn to for help. Health care professionals have a unique opportunity to detect and intervene in domestic violence.

DEFINITION OF DOMESTIC VIOLENCE:
A pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks against one's intimate partner. Without intervention, the violence usually escalates in both frequency and severity resulting in repeat visits to healthcare systems or death (suicide or homicide).

WHAT TO LOOK FOR:

• History inconsistent with injury
• Evasive, reluctant to speak in front of partner
• Unexplained, multiple or old physical injuries
• Delay in Seeking aid
• Injuries during pregnancy
• Repeat visits for treatment of injuries
• Suicidal ideation or physical signs of attempts
• Traumatic injury or sexual assault

CIVIL LIABILITY:
A physician who treats a victim and does not inquire about domestic abuse or accepts an unlikely explanation for the injury could be held liable if the victim returns to the abuser and is injured again.

CRIMINAL LIABILITY:
A violation of reporting law is a misdemeanor punishable by imprisonment in the county jail not exceeding six months or by a fine not exceeding $1000 or both.

IMMUNITY:
A health care practitioner who makes a report shall not incur civil or criminal liability as a result of a report required or authorized by law.

Ask simple direct questions, such as:

• "Is someone hurting you or your children?
• Did someone cause these injuries?
• Are you being threatened?

Tell her or him: "You are not alone. It is not your fault. I am afraid for you and your children. Help is available."

DOCUMENTATION: THE ESSENTIAL ELEMENTS
Complete a legible medical record for each known or suspected victim of domestic violence. Include as much of the following as possible in the medical record:

• Chief Complaint/History of Present Injury or Problem: Elicit and record precise details of the abuse and their relationship to the presenting problem. Include a description of patient's injuries, including type, location, size, color and age. Use a body map. Record the results of any lab tests, x-ray or diagnostic procedures and their relationship to the abuse. Whenever appropriate, use the patient's own words in quotation marks.
• Past History of Abuse: Ask about and record any medical, trauma, obstetrical/gynecologic, psychiatric or substance abuse histories that are related to domestic violence. Document conditions which will affect the patient's safety or ability to deal with the abuse.
• Alleged perpetrator's name, address, and relationship to patient (and children, if any).
• A description of other health problems, physical or mental, which may be related to the abuse.
• Photographs of patient's injuries, whenever possible. Obtain patient's consent, prior to obtaining photos. Include:
• One full body shot (to link injuries with patient)
• One mid-range to show torso injuries on patient
• Close-ups of all wounds and bruises
• Preserve any physical evidence (e.g., damaged clothing, jewelry, weapons, etc.) which can be used for prosecution.
• In the case of rape/sexual assault, follow protocols on physical and forensic examinations and evidence collection, with the patient's consent.

Document details of intervention made and all actions taken. If police report was made: File a copy of the written report in the patient's file.

ASSESS SAFETY/LETHALITY:

• Are you afraid to go home?
• Is your partner threatening homicide or suicide?
• Does your partner have access to weapons?
• Can you stay with family or friends?
• Do you want to go to a shelter?

REPORT, AS REQUIRED BY LAW

A health care practitioner who in his/her professional capacity, or within the scope of his/her employment provides medical services for a physical condition to a patient whom he/she knows or "reasonably suspects is suffering from any wound or physical injury inflicted as a result of assaultive or abusive conduct, including abuse by a spouse or co-habitant, must report the incident to law enforcement 
(view list of Monterey County Law Enforcement Agencies).

*REASONABLY SUSPECTS means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position drawing, when appropriate, on his/her training & experience to suspect domestic violence.

Call the appropriate law enforcement agency immediately or as soon as possible.

Submit the Suspected Violent Injury Report form to the law enforcement agency within 2 working days. The required reports are confidential.

TELL ABUSED PATIENTS: help is available.

MAKE APPROPRIATE REFERRALS to community resources whenever abuse is present, whether or not the situation is reportable to law enforcement.

ACKNOWLEDGMENTS:

This protocol was developed by the Medical Services Workgroup of the Domestic Violence Coordinating Council of Monterey County during the fall of 2001 and the spring of 2002. Members of the workgroup who participated in the development of the protocol include the following individuals:

1. Valerie Barnes, MD, Natividad Medical Center
2. Susan McNelley, RN, PHN, Monterey County Health Department
3. Sheree Nash, NP, SART Nurse, Visiting Nurses Association
4. Robin Nebenfuhr, Monterey County Medical Society
5. Barbara Davies, Domestic Violence Educator, Family Service Agency
6. Dennis Bates, Monterey County Department of Social Services
7. Sheila Snider, MSW, Mee Memorial Hospital
8. Mary Wurth, RN, Community Hospital of the Monterey Peninsula

Printing and assembly costs were assumed by the Women’s Crisis Center, the Monterey County Health Department Perinatal Services Program, and the Visiting Nurses Association.

The workgroup wishes to extend our sincere appreciation to the many other individuals who participated in some way with the development, review, and distribution of the protocol and handout material.