As with all nursing documentation, the record should be non-biased, containing direct observations by the nurse. Use of non-biased terms such as “chooses”, “declines” or “patient states” are more appropriate than using judgmental terms like “alleges” or “victim”.
An example would be “patient states ‘my husband beat me’” (non-judgmental) rather than “victim alleges she was assaulted by partner” (judgmental).
Referral services and secondary intervention would include more detailed documentation such as:
- Relevant health history;
- History of abuse including the first, worst and most recent incident;
- Where and when the abuse took place;
- Name and relationship of abuser;
- Detailed description of injuries and photos (if taken); and
- All health care provided and information and/or referrals to resources provided to the woman.
- When no disclosure of abuse is made the nurse should document “no disclosure to abuse screening”