What does documentation of abuse by a mental health practitioner mean?

Thorough, detailed, well-documented records—have an important role to play in the prevention of abuse. Not only are they important as legal evidence, writing the details of the abuse in medical records in front of the client functions as an act of validation for them.

Documentation of injuries is important, especially if your client decides to go to the police or seek legal help. They will be required to provide evidence of abuse, and your medical records can help give it, as well as indicate when the violence was reported—essential to developing a chronology of events.

Documentation of abuse should include the following—

• Mention the name of the person accompanying the client, and their relationship to them.

• Make a note of the chief complaint and description of the abusive event, preferably recorded in verbatim. Details are important, such as “My husband pushed me against the wall.” Nature, time, and location of events should be mentioned.

• Write a detailed description of the injuries, including—type, number, size, location, fresh or healed, possible causes, and explanations given. The use of a body map/pictorial representation is encouraged.

• Enter in the medical record any health complaints, symptoms, and signs, as you would for any other woman, including a description of her injuries. It may be helpful to note the cause or suspected cause of these injuries or other conditions, including who injured her.

• The laboratory reports or radiological studies ordered, medications prescribed, and when the referral was done. If possible, photographs of any physical injuries (if the client permits) and radiological investigations may be obtained.

• Documentation should also include, comments on co-existing health conditions; pregnancy, if present; and degree of disability.

• Describe the client’s demeanor, indicating, for example, whether she was crying or shaking, or seems angry, agitated, upset, calm, or happy.

• Record the time of day the client comes in for her sessions and, if possible, indicate how much time has elapsed since the abuse occurred. For example, you might write: “The client states that approximately at 11 pm on the night of 10th July 2020, she reported that her husband hit her resulting in bruising near her right eye.”

• If the police were called, the name of the investigating officer if possible, and any actions taken after.

• Family/social history, including the current living arrangement.

As a mental health practitioner, some things to be mindful of when documenting abuse are—

• Write legibly. Computers can help overcome the common problem of illegible handwriting.

• Set off the client’s own words in quotation marks, or use phrases like “client states” or “client reports” to indicate that the information recorded reflects the client’s words. Writing “The client was kicked in the abdomen” obscures the identity of the speaker.

• Avoid phrases such as “client claims” or “client alleges,” which imply doubt about their reliability. If your observations conflict with the client’s statements, you should record the reason for the difference.

• Avoid summarizing a client’s report of abuse in conclusive terms. If language like “The client is a victim of domestic violence,” or “rape” lacks sufficient accompanying factual information, it might not be considered valid in the court.

• Be aware of situations where confidentiality may be broken. Be cautious about what you write where, and where you leave the records. For greater confidentiality, some facilities use a code or a special mark to indicate cases of abuse or suspected abuse.

Handling abuse-related trauma in therapy is a series by White Swan Foundation in collaboration with Shakti. This series is a guide for mental health practitioners to help survivors of abuse heal with therapy. This series refers to survivors as women, however, we acknowledge that survivors can belong to any identity. The usage of the word "women" has been used to reflect laws that are focused on women as survivors of domestic violence, and other guidelines that are framed keeping women in mind.

Written by Bhumika Sahani, journalist and social worker by training; consultant at Shakti; and Dr Parul Mathur, resident doctor, Department of Psychiatry, NIMHANS