Documentation Tips

Documenting your observations, your response to disclosure and the safety plan that has been negotiated is required. There are several reasons why you need to document the process, including:

• Ensuring that the individual does not need to repeat all of the story,

• providing consistency in care,

• providing evidence of abuse in the case of a court appearance. (This is not common but can be vital in establishing that the abuse has occurred).

Be sure to ask the individual’s permission prior to documenting abuse, and never put unnecessary details on referrals or records that could be seen by a partner. In cases of assault it is important for the health professional to document clearly and accurately what the individual has said and a description of any injuries, as clinical notes may become evidence in criminal court proceedings