Module 4: Medical Assessment and Securing of Evidence

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 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 and informed consent should be obtained for every aspect.
  • If they want to go to the police, they are told that they should have forensic evidence secured 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 are ones that need to be considered especially in cases of domestic violence.

Immediately refer patients with life-threatening or severe conditions for 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 traumatized than others. It is important to be able to recognize 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 plan to commit suicide or to harm themselves,


  • 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 immediate risk of self-harm or suicide, and they should not be left alone.

Refer them immediately to a specialist or emergency health facility.

Documentation in cases of domestic violence

Health service providers have a professional obligation to record the details of any consultation with a patient. The notes should reflect what was said, by the patient, in their own words, and what was seen and done by the health care provider. In cases of violence, the taking of accurate and complete notes during the course of an examination is critical as medical records can be used in court as evidence. If the victim consents to a forensic examination, there might be needed to call in a registered or official forensic examiner.

“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.”

You should record sufficiently detailed, accurate and clear notes to show the concerns you have and indicate the harm that domestic abuse may have caused.

  • Always keep a detailed record of what you have discussed with a patient – even if your suspicions of domestic abuse have not led to disclosure. The patient might disclose information in the future.
  • For confidentiality ensure that the record can only be accessed by those directly involved in the victim’s care.
How to document
  • Describe exactly what happened. For example, patient states “my husband kicked me twice in stomach” rather than “patient assaulted”.
  • Use the patient’s own words rather than your own.
  • Document injuries as detailed as possible, using body maps to show injuries, and record whether an injury and a victim’s explanation for it are consistent: “Patient has four small two-pence-sized bruises on her upper arm 2cm apart. Patient reported ‘I fell down, I can’t really remember what happened’”
  • Take photographs (sign and date them) as proof of injuries.