does a nurse document domestic violence even though patient doesn't want to report

by Joany Kuhic 10 min read

Mandatory Reporting of Domestic Violence - Findlaw

31 hours ago  · Despite this, nurses have an important role to play in their work in hospital and community settings, to assist women (and their children) who are victims of abuse/violence in a domestic situation. Evidence shows the effects of abuse/violence have a profound impact on women's and children's health, and that women regularly seek services from ... >> Go To The Portal


Even if a patient experiencing violence decides not to disclose abuse to that particular nurse, on that particular day, she or he may remember the message and talk to another nurse or health care provider, at another time. Data from many different studies show that women, both abused and not abused, accept being asked about domestic violence3, 4.

Full Answer

Do nurses have a duty to report domestic violence?

Federal and state laws require that certain individuals, particularly those who work in health care, with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations. Nurses are listed in most, if not all, mandatory reporting statutes.

What happens if a health care provider fails to report domestic violence?

If the health care provider fails to meet these requirements for mandatory reporting of domestic violence, he or she may be found guilty of a misdemeanor crime. Who Has to Make a Report?

What questions should nurses ask women who are experiencing domestic violence?

If nurses think a woman in their care may be experiencing domestic violence, the detail of questioning will depend on how well they know the woman and what indicators they have observed. Nurses should begin with broad questions, such as: 'How are things at home?' 'How are you and your partner relating?'

How do I document domestic violence in medical records?

Document the facts clearly and objectively and let others draw conclusions in the future. Don't put the term domestic violence or abbreviations such as "DV" in the diagnosis fields of a patient's medical records. These terms don't convey factual information. It's up to the courts to determine whether domestic violence has occurred. 2

What role can nurses play for domestic violence non existent?

Nurses can play an important role in working toward the creation of a violence free community but they must first become informed. They must then insist the organisations in which they work accept this responsibility and work together to create environments that support people experiencing domestic violence.

How should the nurse document the abuse?

When documenting suspected abuse, record only the facts and leave out personal opinions and judgments. Note inconsistencies in histories, evasive answers, delays in treatment, medical attention sought at other facilities, and the person caring for the individual during the incident.

What should be included in the documentation of intimate partner violence?

With the patient's permission, take photographs of all injuries known or suspected to have resulted from domestic violence. If that's not possible, clearly document the location, number, type, and characteristics of injuries, using an injury location chart or body map.

When caring for a person who reports suffering domestic or intimate partner violence the healthcare professional's action is to?

1.2. Recommendation. Women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support. Health-care providers should, as a minimum, offer first-line support when women disclose violence.

Which is the role of the nurse in a domestic abuse situation?

Nurses are involved in caring for women who suffer from abuse, and their role is to help prevent and protect them from further maltreatment by offering support, understanding and empathetic care.

What is the nurse's role in reporting the suspected abuse?

For nurses being a mandated reporter means that it is a nurse's responsibility to report any suspicions of child or adult abuse or neglect. If the story just doesn't fit, the nurse needs to be suspicious. If the child or adult suggest they have been abused, the nurse needs to report.

How should the nurse document an assault such as the one the client just described in the record?

How should the nurse document an assault such as the one the client just described in the record? Write down verbatim the statements that the client makes related to who assaulted her and when. The notes taken about the incident may be used as evidence or future care.

How do you build a case against an abuser?

Building Your Case: How to Document AbuseVerbal testimony from you or your witnesses.Medical reports of injuries from the abuse.Pictures (dated) of any injuries.Police reports of when you or a witness called the police.Household objects torn or broken by the abuser.More items...

Which questions are appropriate for screening for abuse?

Do you feel controlled or isolated by your partner? Does your partner ever try to control you by threatening to hurt you or your family? Has anyone close to you ever threatened or hurt you? Does your partner ever hit, kick, hurt or threaten you?

What are some basic rules for nurses to follow when assessing for violence?

Explanation: Nurses assessing for violence should perform assessment and screening only when the client is alone in a safe, private environment. The nurse needs to establish rapport and connection by showing interest in the client and by listening. The nurse also needs to demonstrate compassion, not judgment.

What is the priority nursing intervention when caring for a patient who is a victim of interpersonal violence?

A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? Providing education that will address immediate safety needs for the patient is a priority action for the nurse.

Why is it important that the victim report the abuse to the proper authorities 1 point?

Reporting can help victims recover from their abuse and help prevent an offender from abusing someone else. Representatives of victim advocacy groups and law enforcement helped map out the process of making the first step to disclosure.

How to document domestic violence?

Objectively document any injuries suggesting domestic violence. With the patient's permission, take photographs of all injuries known or suspected to have resulted from domestic violence. 2 If that's not possible, clearly document the location, number, type, and characteristics of injuries, using an injury location chart or body map.

What is the role of healthcare in domestic violence?

The healthcare community plays an important role in screening, treating, and documenting domestic violence. A healthcare facility may be the first and only setting for disclosures of domestic violence in a safe forum.

How to avoid legalese?

Avoid legalese. Document in a factually neutral manner, avoiding phrases or words such as alleges, which have specific legal meanings.

What to write in a court case about a battered woman?

Don't write your personal conclusions about the situation, such as patient is a battered woman. 2 Conclusions without sufficient accompanying factual information are generally inadmissible in court. Document the facts clearly and objectively and let others draw conclusions in the future.

Why is it important to document facts without implying blame?

Careful documentation that presents the facts without implying blame helps ensure that patients in abusive situations get the help they need to stay safe.

What is the purpose of documentation for a referral to a social worker?

If a referral to a social worker is needed, your documentation should reflect this, as well as any referral to a patient advocate for domestic violence. Careful documentation that presents the facts without implying blame helps ensure that patients in abusive situations get the help they need to stay safe.

Why do you interview patients alone?

Remember to interview patients alone because abusers often accompany their victims when seeking healthcare. Ask patients whether they're safe at home or whether they can stay somewhere else. If a referral to a social worker is needed, your documentation should reflect this, as well as any referral to a patient advocate for domestic violence.

What is the role of nurses in domestic violence?

While domestic violence remains a serious and frequent aspect of women's intimate relationships, and women and children suffer health consequences as a result, nurses have a significant role to play in working toward the prevention and early intervention of domestic violence.

How to tell if a woman has been injured in domestic violence?

When assessing women, nurses should be aware that some of the following physical signs of injuries might be related to domestic violence: Bruising in the chest and abdomen; Multiple injuries; Minor lacerations; Ruptured eardrums; Delay in seeking medical attention; and. Patterns of repeated injury.

Why is it important for nurses to work in hospitals?

Despite this, nurses have an important role to play in their work in hospital and community settings, to assist women (and their children) who are victims of abuse/violence in a domestic situation. Evidence shows the effects of abuse/violence have a profound impact on ...

How many women are subjected to domestic violence in Australia?

A national survey conducted by the Australian Bureau of Statistics found the prevalence of domestic violence in Australia is alarmingly high, with one in five women reporting being subjected to violence at some time in their adult life.

What is family violence?

All of these terms refer to violence that occurs between people who are, or were formerly, in an intimate relationship.

What are the barriers to disclosing domestic violence?

The range of barriers to disclosing domestic violence include: Fear for own safety, or safety of children or other family; Denial or disbelief; Emotional attachment to, or love for partner; Commitment to relationship; Hope the behaviour would change; Shame and embarrassment; Staying for the sake of the children;

What are the reasons why women are afraid of violence?

Shame and embarrassment; Staying for the sake of the children; Depression and stress; Isolation; Lack of faith in other people's ability to help; and. Belief in the value of self-reliance and independence. When women do tell someone about the violence, few approach domestic violence services of the police.

What happens if a nurse fails to report violence?

Indeed, if you as a nurse fail to report an instance of violence when required to do so, you could face professional disciplinary action by the state board of nursing, a loss of any certifications you hold (e.g., certification as a school nurse), and criminal prosecution (usually a misdemeanor). 2

When a mandatory duty to report violence against an individual or individuals exists, there is no exception to the directive?

When a mandatory duty to report violence against an individual or individuals exists, there is no exception to the directive: one must report without fail. This translates into no excuse for not doing so. As a result, nurse-patient confidentiality, another staff member or administrator telling you not to report your concerns, or a family member pleading with you not to report your observations do not affect your duty to report.

What are the statutes for child abuse?

Statutes include child abuse and neglect reporting statutes, medical neglect of children and the elderly, elder abuse in the community or in nursing homes reporting laws, and domestic violence. Reporting statutes have certain conditions and protections the reporter must meet and possesses in order to ensure that the reporting is not done ...

Who to consult with for nurse reporting?

Consult with a nurse attorney or attorney to help guide you with the reporting, especially if you are not supported by your employer;

Who to share concerns with?

Share your concerns with the individual identified in your facility or agency policy to do so (e.g., CNO, Administrator, Risk Manager);

Why is mandatory reporting important?

In some cases, the mandatory reporting of violence discourages domestic violence victims from seeking treatment. Or, a reported incident may spark retribution on part of the abuser. Victims fear that seeking medical attention may place them in even greater peril. Mandatory reporting policies also infringe on the fine line between patient-provider confidentiality. Furthermore, they limits victims’ power over their own lives. Given that the victim has intimate knowledge of the situation, they may feel they are better prepared to take appropriate action themselves.

Is reporting domestic violence beneficial?

As a healthcare provider, my initial reaction to laws mandating the reporting of domestic violence is that, of course, they are beneficial. What kind of person would I be if I noticed someone fall victim to violence without alerting the authorities, at the very least. However, there are a few valid arguments against reporting these acts.

What should a nurse do when treating a patient?

Nurses should provide a calm, comforting environment and approach the patient with care and concern. A complete head-to-toe examination should take place, looking for physical signs of abuse. A chaperone or witness should be present if possible as well.

What is the mandate of a nurse?

As mandated, they are trained to identify signs and symptoms of abuse or neglect and are required by law to report their findings. Failure to do so may result in discipline by the board of nursing, discipline by their employer, and possible legal action taken against them. If a nurse suspects abuse or neglect, they should first report it ...

Do nurses have a responsibility to care for victims of abuse?

Employers are typically clear with outlining requirements for their workers, but nurses have a responsibility to know what to do in case they care for a victim of abuse.

Should a nurse report abuse?

The nurse should notify law enforcement as soon as possible, while the victim is still in the care area. However, this depends on the victim and type of abuse. Adults who are alert and oriented and capable of their decision-making can choose not to report on their own and opt to leave. Depending on the state, nurses may be required ...

Do nurses have to be able to connect victims of abuse?

While not required by law, nurses should also offer to connect victims of abuse to counseling services. Many times, victims fall into a cycle of abuse which is difficult to escape.

What is the mandated reporting for domestic violence in North Carolina?

Mandated reporting is for child abuse and neglect.

What is a mandated report for domestic violence?

Mandated reporting is for child abuse and neglect. For adults the law is clear that when a doctor suspect domestic violence they are to ask the patient if their partner or care giver, family member or friend is harming them. They are to direct nurses to provide all community resources available for assisting the patient and refer them to counselling. In a language they understand. They can refuse.. But They have the info. When you state report, nurses are required to do skin assessments and document bruises, and anything else they see on a drawing of a person. This becomes part of the chart. Naturally, women with children, that have evidence of abuse by a partner are asked where their children were when they got these, bruises. Saying the children were present is puting your children In an at risk situation, at best neglect. In my small community, DCFS will take children out of those situations, if they believe there is an at risk situation for the children. At risk can refer to observing one parent being harmed by another family member including an adolescent child. It is not always a male partner. Violence in the family is genderless.

Why do you need special measures to give evidence?

Because you are a victim of domestic abuse, you should have been offered special measures to assist in maximising your ability to give evidence. There are several. The most common being screens. In essence, a curtain is pulled around the witness box and you will enter the court either by a different door, shielded from view, and/or the court will be cleared so that nobody outside of court staff will see you enter.

What is the number to call for domestic violence?

They are mandated to inform the domestic violence victim about the resources available to them, including providing them the number to the National Domestic Violence Hotline - 1-800-799-SAFE. I believe that this is following the principle that only the victim may know when it is truly safe for them to leave.

What does "at risk" mean in DCFS?

At risk can refer to observing one parent being harmed by another family member including an adolescent child. It is not always a male partner. Violence in the family is genderless.

What is mandated reporting?

Mandated reporting is for child abuse and neglect. For adults the law is clear that when a doctor suspect domestic violence they are to ask the patient if their partner or care giver, family member or friend is harming them.

How much is the penalty for domestic violence?

The penalties may include a fine of $1,000.00 in addition to up to a year in jail followed by twelve months probation. Additionally, as this crime is considered so serious, a person convicted of domestic violence will always have a criminal record as their record can never be expunged or sealed.

What is mandatory reporting for domestic violence?

(Mandatory Reporting of Domestic Violence by Health Care Providers: A Policy Paper, Hyman, A; Family Violence Prevention Fund, 1997) After a report is made, there is no guarantee that there will be an effective law enforcement response that meets the patient's safety needs or that there will be any actions taken to hold batterers accountable.

What to do if your state has a mandatory reporting law?

If your state has a mandatory reporting law that has not been amended to exclude reporting domestic violence injuries, you can still work with providers to help victims stay safe and healthy. In addition to training providers on how to disclose any limits of confidentiality in their setting, especially if you have major concerns about your reporting law and the risks it might pose for patients, providers can always offer universal education about the health consequences of abuse and the resources available in the community for help.

Why is it important to amend the reporting statutes?

Amending health care reporting statutes may help to enable law enforcement officials to more effectively intervene in crimes of domestic violence. Mandatory reporting by health care providers of minor injuries often does not provide the context or evidence needed for law enforcement officials to conduct a thorough investigation. Furthermore, if a report to law enforcement is made without victim consent, corroborating testimony may often be unavailable. Finally, law enforcement intervention without substantial evidence may aggravate the batterer further without leading to arrest. This may place the victim in additional jeopardy.

Who Has to Make A Report?

What Does The Report include?

  • The report on suspected abuse must include the name of the patient, the patient's location, a description of the patient's injuries, and the name or identity of the abuser (if the identity is known). These are minimum requirements. The report itself can go into more detail about the suspected abuse if the healthcare provider feels that further description will help. One question …
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What Should Be Done After The Report?

  • Sending in a report to local law enforcement authorities may cause new problems for the patient. Law enforcement may show up at the patient's house and question the family about abuse, may make an arrest or issue charges, and more. When the behavior of an abuser is questioned, criticized, and potentially investigated, then this can create a dangerous environment for the pati…
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Consider Getting Legal Assistance with Mandatory Reporting of Domestic Violence

  • If you're in a position to report an incident of domestic violence, it's critical to take action as soon as possible. In many instances, the domestic violence incidents recur and can get progressively worse and you could face criminal charges for failing to report. If you want to learn more about mandatory reporting of domestic violence, you should...
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