Family violence: your medical record obligations

Family, domestic, and sexual violence is a major health and welfare issue. It affects people of all ages and from all backgrounds.

As a doctor, you may see a patient that you are worried is a victim of family violence. Sometimes knowing what and how much to document in the medical records can be challenging. This can be because of the sensitive nature of the information, or because of patient safety concerns, especially if other family members attend your practice or are present during a consultation. However, it is important to be aware of what your medico-legal obligations are in these circumstances.

The purpose of medical records

The primary purpose of medical records is to document clinical information for use in patient management and as a means of communication with other doctors and health professionals. The records should include enough information to ensure another doctor can pick up the record and continue the patient’s care.

A patient may not explicitly tell you they are experiencing family violence, but if you suspect they are, asking direct and indirect questions can help you understand the nature of the abuse and document the conversation in the patient’s medical record.

An indicator of standard of care

Good records are key when considering the standard of care. Think about what information you would need to know from a colleague’s records if you were taking over care of the patient.

The Medical Board’s Code of Conduct states that good medical practice includes:

• 10.5.1 Keeping accurate, up to date and legible records that report relevant details of clinical history, clinical findings, investigations, diagnosis, information given to patients, medication, referral, and other management in a form that can be understood by other health practitioners.
• 10.5.3 Ensuring that your medical records show respect for your patients and do not include demeaning or derogatory remarks.

College guidelines, such as The Royal Australian College of General Practitioners White Book and Australasian College for Emergency Medicine policy on Family and domestic violence and abuse, are also useful resources in managing patient care in this situation.

What should you include in the record?

Like any other patient interaction, consider what you write and the language you use in the records. Document what the patient tells you, including health complaints, symptoms and signs, and any history of abuse and who injured the patient.

Describe the characteristics of every injury, including the type of injury, its clinical features, location and size.

Record what the patient said using quotation marks and note any behaviour you observed, for example, ‘the patient cried when speaking about ….’ These details will be useful in case you need to write a police report or alert another health professional.

Photographs of the injuries before treatment can be helpful as a record of appearance and a visual reminder. Ensure you obtain and document consent before you take any pictures.

A patient may ask you to withhold certain information from their medical record. If they do, explain you are required to document what is discussed in the consultation and reassure the patient the medical records are confidential. In some circumstances it may be appropriate to use the ‘confidential’ function in your medical records software for certain details.

Finally, in agreement with the patient, document a plan, including agreed steps in relation to patient/family safety.

Key lessons

If talking to a patient about suspected family violence, it is important to document your discussion.

Your notes should include the patient’s health complaints, symptoms, and signs, and any information from the patient about who caused the injury and how. This may include photographs, if you have documented patient consent.

Make it clear in your notes what information was reported by the patient and include direct quotes and reference to the patient’s demeanour or behaviour as appropriate.

If your patient is reluctant for you to document anything, advise them you are required to do so and reassure them your records will remain confidential.

Useful resources

Avant factsheet: Medical records: The essentials

Primary Health Networks NSW webinar: “Too Little, Too Much" Recording domestic and family violence disclosures in general practice

The RACGP: The White Book

Australasian College for Emergency Medicine: Family and domestic violence and abuse policy

Reference

1. Australian Institute of Health and Welfare. 2022. Family, domestic and sexual violence in Australia: continuing the national story 2019, Summary - Australian Institute of Health and Welfare. [online] Available at: https://www.aihw.gov.au/reports/domestic-violence/family-domestic-sexual-violence-australia-2019/contents/summary [Accessed 18 July 2022].