Screening and recording

Routine or universal screening is an effective way to identify victims of DVA. Asking all patients the same standard questions can help to legitimise the need for a conversation about DVA and effectively communicate to the woman that she is not alone in her experiences.

Women who screen positive are more likely to experience DVA in the next few months. Therefore, screening can help to protect them from further victimisation as well as prevent long-term fatal consequences such as homicide or suicide.

There are various methods of screening:

• Computer-based
• Written or pen and paper
• Audiotape questionnaires
• Verbal screening

Computer-based screening is a particularly effective method as the victim can answer various questions without being interrupted or feeling judged and embarrassed. It provides a sense of confidentiality that may help patients to respond better.

Verbal screening methods can also be effective if you are able to develop a trusting relationship with the patient. In such cases, building rapport and trust will help the victim to disclose information more comfortably.

Examples of screening tools used within the healthcare professions include:

The most commonly used tool in the UK is the Domestic Abuse, Stalking and Honour Based Violence (DASH).

Gathering and recording information

If you suspect a patient may be experiencing DVA, it’s important that you keep a detailed record of your assessment. It may serve as evidence in any legal proceedings that the patient might want to undertake.

You don’t need a patient’s permission to make notes but it’s important that you directly communicate that as part of your duty of care, you are required to keep a record of their disclosure and injuries.

Record what the patient has said (using quotation marks) and any relevant behaviour you have observed.

If the patient has physical injuries, document any details about them, including the type, extent, age and location. If you suspect DVA is a cause, but your patient has not confirmed this, it may be relevant to note whether their explanation of the injuries is consistent with the presentation.

With the consent of the victim, you may also consider taking photographs of the injuries, making sure to date and sign them as proof.

The following information should be recorded in the notes:

• Your suspicion of DVA and whether or not it has resulted in disclosure
• If you have made a routine or selective enquiry and the response
• Detail about the perpetrator (relationship, name)
• If the woman is pregnant
• If children live in the same household and the age of the children
• The type of abuse experienced (psychological/ physical abuse)
• Description of specific recent DVA incident
• Duration and frequency of DVA
• Any injuries and specific details
• Presence of increased risk factors
• Detail of the information provided on local sources of help
• Detail of the action taken (referral)

The safety of the victim is paramount. Records should only be accessible to those directly involved in the provision of their care and should not be visible on the opening screen of their record.

On the next step, we’ll look at what further steps you can take to ensure the victim is safe.

What do you think?

• Within your own area of practice do you currently use a DVA assessment tool?
• What are your thoughts about its usefulness?
• If you have never used a DVA assessment tool, you might like to consider one of the tools mentioned and how this could be useful to you.