Module 4: Medical assessment and securing of evidence

Medical examination and securing of evidence
Imminent risk of suicide and self-harm
Documentation in cases of domestic violence

Learning objectives

This module presents the most important aspects to be considered after the disclosure of domestic violence and how to document domestic violence injuries for legal trials. The learning materials are not tailored to the needs of every country; they include generic cases that need local adaptation.


The following aspects should be considered after the disclosure of domestic violence.

  • The medical history should follow standard medical procedures, but it should be remembered that victims who have experienced domestic violence are likely to be traumatised. Any papers they may have should be checked and one should avoid asking questions they have already answered.
  • Every aspect of the examination should be explained. Informed consent should be obtained for every aspect.
  • If they want to go to the police, they should be told that they need secured forensic evidence and what the evidence gathering would involve.
  • If they have not yet decided whether or not to go to the police, the evidence can be secured and stored.
  • If victims want evidence secured, they can contact a specially trained provider, such as a violence victim outpatient clinic, who can do this if you do not feel prepared enough to secure evidence.
  • A thorough physical examination should be carried out. Findings and observations should be recorded clearly and concisely with the help of body maps.
  • The findings in the patient’s medical records are documented in the patient’s own words, but further questions are also asked if necessary.
  • A victim of domestic violence should not be forced to talk about the assault if he or she does not want to. Questions should in all cases be limited to what is necessary for medical care.

Medical examination and securing of evidence

You already are the expert for medical examination, treating of injuries and securing of evidence. The following aspects need to be considered especially in cases of domestic violence.

Immediately refer patients with life-threatening or severe conditions to a facility of emergency treatment.

Mental health problems

Many victims who are subjected to domestic violence will have emotional or mental health problems as a consequence. Once the violence, assault or situation passes, these emotional problems may get better. There are specific ways health service providers can offer help and techniques to victims to reduce their stress and promote healing.

Some victims, however, will be more severely traumatised than others. It is important to be able to recognise these victims and to help them obtain care.

  • Give referral to a psychotherapist

Imminent risk of suicide and self-harm

Some health care workers fear that asking about suicide may provoke the victim or perpetrator to commit it. On the contrary: talking about suicide often reduces their anxiety around suicidal thoughts and helps them feel understood.

  • If they have current thoughts or plans to commit suicide or to harm themselves,

OR

  • if they have a history of thoughts or plans for self-harm in the past month or acts of self-harm in the past year, and they are now extremely agitated, violent, distressed, or uncommunicative, then there is an immediate risk of self-harm or suicide, and they should not be left alone.

Immediately refer them to a specialist or emergency health facility.


Documentation in cases of domestic violence

Recognising and addressing possible experiences of violence and offering protection and referral to the help system are important. In addition, a comprehensive examination and forensic documentation of physical injuries as well as securing any traces of sexual violence are an essential part of primary care. Forensic documentation goes beyond regular medical documentation. It is of great importance for the criminal prosecution of the offence(s) and can significantly support victims, for example, in clarifying questions of access and custody or in questions of residence law. Medical documentation of findings is often the only proof that victims have experienced physical domestic violence. Documentation that can be used in court needs to be confidential. Police-independent securing of evidence is of importance for victims who want to report the crime at a later point in time. Careful documentation is also important for physicians examining the victim, as it provides a valuable basis for any testimony that may be given later.

»A professional forensic documentation is the key evidence for the court proceeding […]«
Great explainer video by UniversitätsKlinikum Heidelberg


IMPRODOVA: How to document domestic violence in the health sector

The video describes the documentation of cases of domestic violence in the health care sector.


“The solicitors said there just wasn’t enough evidence on my health records. Nothing to suggest my ex was to blame for my injuries. I was so let down. I thought my doctor had written down everything I said.”



Basics for forensic documentation and securing evidence

Use documentation sheet and kit for evidence recovery

Always use a documentation sheet and evidence collection kit for documenting injuries and securing evidence. This will guide you through the medical assessment and support you in a systematic approach.

Document in a way that is understandable for laypersons

Your documentation is primarily used by non-medically trained persons such as lawyers, police, members of the judiciary system and other authorities. Document in a way that is understandable and readable for these professional groups; avoid abbreviations and medical terminology.

Describe, do not interpret

Document purely descriptively! Refrain from interpreting findings, such as estimating the age of the wound or assessing whether an injury was inflicted externally.

First document, then supply

If possible, document injuries before they receive medical care. If treatment of injuries has highest priority, check whether photographic documentation of the untreated injury (injuries) is possible. If sexual violence is involved, remember to keep material (e.g., clothing) that may contain traces of the perpetrator’s DNA.

Photograph injuries

Photographs are particularly informative and can supplement written documentation. Injuries in the vaginal or anal area should only be photographed if the findings are clear.

Secure evidence

As a rule, evidence is only collected in connection with sexual violence. As far as possible, it is carried out by the specialist who also provides the medical care. For female victims, a gynaecologist, for male victims a urologist, abdominal surgeon, or trauma surgeon (or surgical service) should be available. If the patient has not (yet) reported the crime to the police, it is possible to secure evidence confidentially.


Essential content of the documentation

General data

Information on the patient, the examining person, other persons present, including interpreters, as well as information on the place and time of the examination is required.

Anamnestic information

Note down anamnestic information only to the extent that it is relevant to the injury. Information on the date, approximate time, and place of the event, on any tools used, on persons involved or present, on the patient’s condition/consciousness at the time of the examination as well as brief details on the course of events (what happened when, where, how, by whom) are essential. If you use an additional sheet besides the documentation sheet, label it like the documentation sheet: with date, time, patient data. Write down information about the event in verbatim. This makes it clear that the information comes from the injured person and not from your own interpretation. Indicate who gave the information if it was not the patient himself/herself.

Survey of findings

Follow the guidelines of the documentation sheet you use. Document both positive and negative findings. If you have not examined a body region, make a note of this, and indicate the reason – e.g., “patient refuses”. A full body examination is recommended.

Attacks against the throat

An investigation is particularly urgent in cases of suspected assault against the throat (strangulation/choking). In terms of criminal law, this may be an attempted homicide. Injuries that give an indication of this sometimes disappear quickly. Always document: stasis bleedings (petechiae) in the eyelids and conjunctiva, the oral mucosa, or the posterior ear region (relevant reduction of blood outflow); temporary unconsciousness; perceptual disturbances (so-called aura), loss of control over the excretory organs, sore throat, difficulty swallowing and globus sensation.

Description of findings

Describe each injury in the dimensions: localisation, shape/boundary, size, colour, type. If possible, use a table to describe the findings. Draw each injury in a body map. This will give you an overview of the location and, if necessary, concentration of injuries on the body.

Photographic injury documentation

Use a digital camera. Use a scale to mark the proportions, ideally an angle ruler. Note the date and the patient’s name for each image. If you use the in-camera display, check that the settings are correct. Take at least two photographs per injury: one overview photograph for orientation of the injury on the body, and one detailed photograph of the injury with scale and, if necessary, a colour chart. Take photographs at right angles to the injury (perpendicular) and hold the scale directly to the injury. Photograph against a neutral background and with good indirect lighting if possible. Check on the display whether the injury is depicted clearly and completely. If in doubt, take more photos. Store all the photos in a safe place (case-related memory card, password-protected folder). Delete all the pictures from the camera or reformat the SD card. Only photograph findings on sensitive body regions such as breasts or genitals if there are clear findings such as lacerations, bites, injuries caused by objects or burns. Do not take a complete picture of the genitals. Only pass on printed photos in an envelope.


Special aspects of sexual violence

Police complaint

Forensic documentation and securing of evidence after sexual violence can be done with or without a police report by the patient. Clarify whether the patient has filed or wishes to file a complaint. Be aware of time frames for securing evidence and what is available at the time of presentation. In the case of patient-commissioned documentation or confidential securing of evidence, documents are kept and only handed over to the police on request, e.g., in the case of a later police complaint. A written release from confidentiality and consent to the release of the documents is always required.

Medical assessment and securing of evidence

Wear sterile surgical gloves to avoid contamination, e.g., of DNA traces with your own DNA. Keep aqua dest. in small packages ready. Take the swabs listed in your documentation sheet for each designated examination step. Only work with self-drying swabs. Use the information provided by the patient to decide where to take the swabs. If the patient is unable to provide any information, it is imperative that you carry out a complete trace collection (as specified in the documentation form/kit).

  • Samples for the toxicological examination: in principle, it is recommended to secure a blood and urine sample to prove or exclude a recent ingestion of narcotics, drugs or alcohol. If necessary, a hair sample can be additionally secured – 4 weeks after the indicated ingestion at the earliest.
  • Roofies: in cases of unexplained unconsciousness or memory lapses, consider the possibility of unknowingly administered drugs.
  • Clothing: secure clothing that was worn at the time of the crime – it could contain DNA evidence of the perpetrator. Pack clothes in individual paper bags. Seal the bags and label them with the patient’s name and date for later identification.
  • Genital or anogenital examination: the urinary bladder should not be emptied until after the examination. Examine the external genitals and perianal area for injuries and foreign bodies first (before introducing the speculum).
  • Vaginal examination: if no vaginal penetration has taken place, a vaginal examination is not necessary. However, it should always be offered. Examine the vagina and cervix for injuries and foreign bodies.
  • Examination of the male genitals: examine the penis and testicles for injuries, paying particular attention to bite injuries to the penis or bruising of the testicles.
  • Anal examination: inspection of the anus is best done in the lateral position with the legs drawn. If injury to the rectum or anal opening is suspected, a proctological examination should be performed.
Medical care

Clarify whether emergency contraception is necessary/wanted. Together with the patient, weigh up the risk of HIV infection or another sexually transmitted disease and proceed according to current professional standards. If necessary, refer the patient to a facility for HIV counselling and/or HIV postexposure prophylaxis (CAVE: if indicated, HIV PEP must be started as soon as possible and within 72 hours).


Final information, psychosocial and medical follow-up

  • Provide the patient with a copy of the documentation sheet and photos if requested. Address security issues regarding storage (access by the perpetrator?). Point out that he/she can keep and use the copy for as long as he/she wishes.
  • Ask about the patient’s and, if applicable, their children’s safety and protection needs. If there are indications of a possible risk, and if the patient does not want to return home, refer him or her to support facilities.
  • Inform the patient about psychosocial counselling services that support him or her in coping with the violence suffered and in clarifying options for action. Support the patient in making contact. Make an appointment with him or her, e.g., at a specialised counselling centre for domestic and/or sexual violence. Provide written information on how to cope with the experience.
  • If children are involved, inform the patient about possible consequences for the children and about support services. Use the existing rules in your clinic/practice for dealing with child protection cases.
  • Discuss any medical follow-up that may be required by the patient. If possible, offer an appointment or arrange one elsewhere. If necessary, give the patient a doctor’s note for further care.

Source: Adapted from Recommendations for forensic documentation and securing evidence after domestic and sexual violence for medical practices and hospitals in Berlin (available in German)