Domestic Violence and Abuse Documentation

Healthcare providers should accurately and completely document the findings of any examinations and any other information relevant to domestic abuse.

This allows appropriate follow-up and supports survivors to access advocacy, police and legal services, while at the same time protecting confidentiality and minimising distress.

The approach to documenting DVA in maternal healthcare will be driven by local policy. It is good practice to seek the person’s informed consent to document (in writing, photographs/videos, recording devices) the details shared with you and to hold this information securely until a later date, and ensure they know who you may share it with (maternity team members, safeguarding teams, the GP/family doctor and so on), how information may be used and any limits to confidentiality.

Maternity units should devise markers to record DVA enquiry and disclosure discreetly, consistently, and safely in notes such that only other midwives in the team will recognise the markers. You need to ensure documentation is not entered onto shared paper or digital maternity records that may be viewed by the abuser.

Check with the local process for documentation and any covert alerts on records that may indicate records are held elsewhere. How this information is shared across agencies also needs to be understood by team members – for example, from antenatal care to postnatal care (health visitors in the UK) or primary care providers. Do not assume electronic systems are shared.

Check with the local information sharing process and with safeguarding leads. Verbal handovers are best if they can be supported confidentially and with consent from the individual. Don’t forget to document what information has been shared verbally with whom and when. If you suspect and ask about DVA, but the person does not disclose, you should document in the medical record (eg in free text, that they have been asked about DVA).

There is frequently a tension between the needs for documentation/sharing information and enabling disclosure of DVA in healthcare. For example, victims may be discouraged from disclosing about their experiences for fear about what will be recorded and shared about them.

Try to clarify the person’s concerns, being mindful that they may be withholding consent due to fear or coercion. You should address any concerns and emphasise the benefits of sharing for their welfare and safety. Recording the disclosure as it is made may distract from giving the person your undivided attention. It helps to build trust and rapport first; ensure you actively listen to the individual, inquire about their circumstances, needs and concerns, and validate their experiences and feelings.

Note-taking may be experienced as disempowering if done without transparency, explanation or the individual’s permission. They may be more comfortable to give that permission if they have been approached with care and compassion, treated with respect and given explanations for different procedures and practices. It is important not to insist that the person answers or discloses information that may cause them trauma or compromise their safety.

In some cases, it will be appropriate for providers to share the DVA information without consent (for example, because sharing is needed for the person’s benefit, to prevent harm, or to raise a formal safeguarding concern). Healthcare professionals who decide to share information without the patient’s consent should follow guidance from their own profession. For detailed recommendations on documenting and sharing data in relation to DVA in maternity and other healthcare services (UK), see Dheensa (2020).

Tips for documenting domestic violence and abuse include:

_{(Dheensa, 2020; Lentz, 2011; World Health Organization, 2019)}

References

_{Dheensa S. (2020). Recording and sharing information about domestic violence abuse in the health service report: Research report and good practice recommendations for healthcare. University of Bristol. Web link}

_{Lentz, L. (2011). 10 tips for documenting domestic violence. Nursing Critical Care, 6(4), 48. DOI link}

_{World Health Organization. (2019). Caring for women subjected to violence: A WHO curriculum for training health-care providers. Web link}