Note: Due to the sensitive nature of IPV, prioritize patient safety and confidentiality throughout the encounter.
Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Reason for Visit:
Document the reason for the visit. This may include:
Disclose current or past IPV.
Seeking medical attention for injuries sustained from IPV.
Follow-up visit after previous disclosure.
Safety Assessment
Conduct a private and confidential safety assessment using a validated tool (e.g., HINTS). Do not document details of the assessment in the progress note.
Document the general level of safety risk identified (e.g., high, medium, low).
If high risk is identified, take immediate steps to ensure patient safety.
History of Present Illness:
Explore the current situation:
Is the partner present?
Is there a history of physical, emotional, or sexual abuse?
Are there threats or concerns about future violence?
Explore the impact of IPV on the patient’s physical and mental health.
Use non-judgmental language and open-ended questions.
Past Medical History:
Inquire about any past disclosures of IPV or related injuries.
Document any mental health conditions potentially related to IPV (e.g., depression, anxiety).
Social History:
Explore the patient’s support system (family, friends).
Assess for social isolation or dependence on the abusive partner.
Physical Examination:
Document any injuries sustained from IPV (location, severity).
Maintain a patient-centered approach and prioritize the patient’s comfort.
Assessment/Plan:
Safety Planning:
Collaborate with the patient to develop a safety plan considering their specific situation.
This may include emergency contact information, escape routes, and safe haven locations.
Document the safety plan in a separate, confidential location.
Documentation:
Document the IPV disclosure using objective terms (e.g., “patient reports history of physical abuse by partner”).
Avoid using judgmental language or victim-blaming.
Treatment Options:
Discuss potential treatment options, including:
Individual therapy or counseling
Support groups for survivors of IPV
Legal advocacy and resources
Emphasize the patient’s autonomy in decision-making.
Referral:
Consider referrals to domestic violence shelters, legal aid, or mental health professionals based on the patient’s needs.
Follow-Up:
Schedule a follow-up appointment to assess safety, treatment progress, and ongoing support needs.
Additional Considerations:
Document any limitations to the history obtained due to safety concerns.
If the patient is unable to disclose abuse but safety concerns exist, document your observations and rationale for further evaluation.
Maintain confidentiality within legal and ethical boundaries. Report suspected child abuse to the appropriate authorities.
Remember:
* The priority is patient safety and well-being.
* Be patient, supportive, and believe the patient’s experiences.
* Empower the patient with knowledge and resources.