As with any case within the human services field, documentation of the client’s history is a must. Centre County Hospital urges professionals to preface patient’s statements with “patient states”. With the documentation of the injuries, a thorough and extensive evaluation is needed. When taking notes, once is urged to be as complete and descriptive as possible. Although a patient may be reluctant due to modesty, she should completely undress for the examination. Furthermore, photographs should be taken for further evidence should the perpetrator be taken into custody and prosecuted.The final part of the documentation should be the actual diagnosis of abuse. Centre County Community Hospital suggests that during the course of the initial interview if a patient states that she has been abused to add in the case notes “alleged abuse”. If the woman firmly denies abuse and the interviewer is not convinced, she or he should add “suspected abuse” or “injuries suggestive of battering” in the case notes. Non injurious evidence of assault and battery should be noted. Broken jewelry, torn clothing, and damage to other personal property can be used as evidence.
The Danger Assessment
Helping a patient assess her immediate danger from the abuser is the critical aspect of the interview and examination. Law enforcement should separate the woman from her partner during the entire interview and examination. During this time she should be given the chance to making phone calls in isolation. Afterwards it should be asked if she has a safe place of refuge to go, whether it’s her own home or the home of a friend or family member. Unfortunately, according to the Women’s Rural Advocacy Program, women who are in the process of leaving their abusers are at a 75% higher risk of being killed then women who stay with their partners. Since 50% of homeless women and children in the United States are running from abuse, the interviewer should assess whether the patient needs boarding at a shelter, or police/legal intervention. If the patient has children, their whereabouts should be known. An assessment on their safety should be made since they are likely to have been abused as well. Studies indicate that 70% of men who abuse their partners sexually or physically abuse their own children.