Conceptualizing Domestic Violence Within Clinical Documentation.

Area of Science:

• Public Health
• Medical Sociology
• Emergency Medicine

Background:

• Domestic and family violence (DFV) is a pervasive global issue with profound consequences for victim-survivors.
• Emergency departments (EDs) are critical initial contact points for individuals experiencing DFV.
• Effective documentation of DFV in clinical notes is vital for patient management and interprofessional communication.

Purpose of the Study:

• To explore how healthcare professionals document domestic and family violence (DFV) in the medical records of women presenting to the emergency department (ED).
• To identify patterns and challenges in the documentation of DFV within emergency care settings.

Main Methods:

• A qualitative descriptive study was conducted.
• Clinical notes from 43 presentations involving 32 women (aged 18-56) who reported DFV in a regional ED were analyzed.
• Inductive content analysis was used to categorize the documentation of DFV.

Main Results:

• DFV was documented through direct patient quotes, unambiguous descriptions, unconfirmed instances, and references to problematic relationships.
• While many DFV instances were clearly recorded, a significant portion of clinical notes showed reluctance or caution in acknowledging DFV dynamics.
• Four categories of DFV documentation emerged: direct speech, unambiguous DFV, unconfirmed DFV, and problematic relationship.

Conclusions:

• Findings highlight a need for enhanced and consistent professional training for healthcare providers on identifying, documenting, and responding to DFV disclosures and suspicions.
• Improved documentation practices are essential for better supporting victim-survivors in EDs and other healthcare settings.
• Addressing the nuances in DFV documentation can improve patient care and safety for those affected by domestic and family violence.