R = Routinely Screen Female Patients

Although many women who are victims of IPV/DV will not volunteer any information, they will discuss it if asked simple, direct questions in a nonjudgmental way and in a confidential setting. Interview the patient alone.

A = Ask Direct Questions

• "Because violence is so common in many women's lives, I've begun to ask about it routinely."
• "Are you in a relationship in which you have been physically hurt or threatened?" If no, "Have you even been?"
• "Have you ever been hit, kicked or punched by your partner?"
• "Do you feel safe at home?"
• "I notice you have a number of bruises; did someone do this to you?"
  
  
• If the patient answers "yes": Encourage her to talk about it: "Would you like to talk about what has happened to you?" "How do you feel about it?" "What would you like to do about this?"
  
  Listen nonjudgmentally. This serves both to begin the healing process for the woman and to give you an idea of what kind of referrals she may need. Often a battered woman believes her abuser's negative messages about her. She may feel responsible, ashamed, inadequate and afraid she will be judged by you.
  
  
• Validate her experience. Make sure she knows she is not alone. Millions of women of every age, race, and religion face abuse, and many women find it extremely difficult to deal with the violence. Emphasize that when she wants help, it is available. Let her know that domestic violence tends to get worse and become more frequent with time and that it rarely goes away on its own. "You are not alone." "You do not deserve to be treated this way." "Help is available to you."
  
  Tell her the abuse is not her fault. Explain that physical violence in a relationship is never acceptable. There's no excuse for it - not alcohol or drugs, financial pressure, depression, jealousy or any behavior of hers. "No one has to live with violence." "You are not to blame." "What happened to you is a crime."
  
  
• If the patient answers "no", or will not discuss the topic: Be aware for any clinical signs that may indicate abuse: injury to the head, neck, torso, breasts, abdomen or genitals; bilateral or multiple injuries; delay between onset of injury and seeking treatment; explanation by the patient which is inconsistent with the type of injury; any injury during pregnancy, especially to abdomen or breasts; prior history of trauma; chronic pain symptoms for which no etiology is apparent; psychological distress such as depression, suicidal idealation, anxiety and/or sleep disorders; a partner who seems overly protective or who will not leave the woman's side.
  
  If any one of these clinical signs are present, ask more specific questions. Make sure she is alone. "It looks as though someone may have hurt you. Can you tell me how it happened?" "Sometimes when people feel the way you do, it may be because they are being hurt at home. Is this happening to you?"

D = Document Your Findings

Record a description of the abuse as she has described it to you. Use statements such as "the patient states she was . . . "If she give the specific name of the assailant, sue it in your record. "She says her boyfriend John Smith struck her . . ." Record all pertinent physical findings. Use a body map to supplement the written record. Offer to photograph injuries. When serious injury or sexual abuse is detected, preserve all physical evidence. Document an opinion if the injures were inconsistent with the patient's explanation.

A = Assess Patient Safety

Before she leaves the medical setting, find out if she is afraid to go home. Has there been an increase in frequency or severity of violence? Have there been threats of homicide or suicide? Have there been threats to her children? Is there a gun present?

R = Review Options and Referrals

If the patient is in imminent danger, find out if there is someone with whom she can stay. Does she need immediate access to a shelter? Offer her the opportunity of a private phone to make a call. If she does not need immediate assistance, offer information about hotlines and resources in the community. (Resources for Domestic Violence in Florida can be found in the "Resource" section near the end of this course).

Remember that it may be dangerous for the woman to have these in her possession. Do not insist that she take them. Make a follow-up appointment to see her or some other method of checking in.

1. Assess trauma.
2. Document with body map/photos and description.
3. Refer or treat as appropriate.
4. Report to police if gunshot or knife wound or according to State law.

1. Ask about forced or undesired sex.
2. If NO: document only. If YES and not IPV/DV RAPE: examine for injuries, treat, refer, document. Discuss contraceptive options, prevent pregnancy and STDs.
   If YES and IPV/DV RAPE (within last 72 hours do pelvic exam, evidence collection); examine for injuries, treat, refer, document. OFFER pregnancy test and STD/HIV test.

1. Assess site, type, severity, and duration.
2. If NO: document only.
   If YES: assess pain in relation to violence history and its possible influence on sign/symptoms/illnesses, especially: Neurological, GI/Abdominal, GYN, Chronic stress, Other. Document, refer and/or treat.

1. Screen for current substance abuse problems of patient and abuser.
2. If NO: document. If YES: inform of treatment options and refer if interested at this time. Document.
3. Reinforce that this is a separate health problem from IPV/DV although it may be exacerbated by or exacerbate IPV/DV.

1. Assess symptoms of depression, severity and duration and relationship to IPV/DV history.
2. Assess client's need for medication. If appropriate, prescribe psychotropic medication and/or refer for psychiatric services or counseling.
3. Using danger assessment guidelines assess for: suicide/homicide potential or attempts.
   If YES, refer for psychiatric consult. Document. Review legal protections available for homicide prevention.

1. Assess sleep, startle, anxiety, re-experiencing of trauma (flashback), numbing.
2. If YES, refer for psychiatric consult.

1. IPV counselor meets with patient.
2. Assess trauma history.

1. Marital status with abuser: married, separated, divorced, widow, single.
2. Living with abuser: yes, no, sometimes.
3. Harassment and/or stalking by abuser?
4. Children: number and ages. Custody?
5. Health insurance: none, abuser's policy, personal policy.

1. During woman's treatment/hospitalization: children living with patient? Where are they now? How can their safety and care be assured? How support mother's custody?
2. Child trauma: ask if children demonstrating signs of trauma from observing violence (i.e., sleep problems, nightmares, aggressiveness or withdrawal, school problems). Refer if indicated.

1. Use Danger Assessment guidelines to assess IPV severity and extent of danger (A Danger Assessment can be accessed in the Appendices of the Guidelines-see Resource section of this course). Express concern for safety.
2. Explain police services. Ask if victim desires for provider to call police.
3. Explain court ex parte/protection orders and victim's services and legal assistance options. Give resource sheet.
4. Explain mandatory legal reporting of child abuse. Inquire if children have been abused and refer if indicated.

1. Use guidelines to assess safety behaviors and plans for future.