Skip main navigation

Domestic Violence and Abuse Documentation

Learn more about domestic violence and abuse documentation.
© Coventry University. CC BY-NC 4.0

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:

Use a structured format for recording the findings. Indicate who is present
Identify the person responsible as stated by the service user

Use quotation marks when recording the identifying information. For example, “My husband,” “My step-mother,” or “My wife kicked me.”
Who else is in the household, noting any children and their ages and any adults at risk.

Objectively document any injuries suggesting domestic violence and abuse

Health providers should focus on details relevant to the provision of maternal and child healthcare. Explain the reason for documenting injuries and options. With the patient’s informed consent, take photographs of injuries known or suspected to have resulted from domestic violence. If that’s not possible, clearly document the location, number, type, and characteristics of injuries, using an injury location chart or body map (see resources from Futures without Violence).

Use quotation marks to denote precisely the patient’s own words

Capture verbatim statements or use phrases such as ‘Service user states …’ or ‘Service user reports …’

Document in a factually neutral manner (avoid using terms like ‘alleges’ or ‘alleged’) and avoid personal conclusions about the situation
Record your observations of the person’s general appearance or demeanour
Write legibly or use a computer to document the information
Handle all collected information confidentially

Share information only after obtaining permission from the person and only on a need-to-know basis, in order to provide care.
Store the information securely in a locked cupboard or password-protected file; anonymising identifying information; and not disclosing any identifying information about a specific case to those who do not need to know, and especially not to the media).

Following local policy and procedure and the law

Report any disclosure that concerns abuse of a child or vulnerable adult to local authorities.
Know the reporting laws relevant to your setting, and document whom you notified of the suspected abuse.

Record actions taken or planned actions including decisions to share information without consent

Action may include referrals, signposting, safety-planning and information shared. If there is no action, this should be recorded along with the reason for taking no action.

(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

© Coventry University. CC BY-NC 4.0
This article is from the free online

Identifying and Responding to Domestic Violence and Abuse (DVA) in Pregnancy

Created by
FutureLearn - Learning For Life

Our purpose is to transform access to education.

We offer a diverse selection of courses from leading universities and cultural institutions from around the world. These are delivered one step at a time, and are accessible on mobile, tablet and desktop, so you can fit learning around your life.

We believe learning should be an enjoyable, social experience, so our courses offer the opportunity to discuss what you’re learning with others as you go, helping you make fresh discoveries and form new ideas.
You can unlock new opportunities with unlimited access to hundreds of online short courses for a year by subscribing to our Unlimited package. Build your knowledge with top universities and organisations.

Learn more about how FutureLearn is transforming access to education