Patients hurt during intimate partner abuse are crime victims who may seek legal relief and protection from one or more court systems. What the health care provider documents or does not document may have tremendous forensic implications; yet, most health care providers have received little formal training in clinical forensics. Being subpoenaed to court as a witness can trigger fear and anxiety. This article reviews the basic principles of clinical forensic documentation, evidence collection and preservation, forensic photography, and accurate wound identification, as well as tips on working with police and on testifying in court.
With the passage of more comprehensive domestic violence legislation, increasing numbers of women hurt by intimate partners (male or female) are accessing one or more court systems to seek relief from further violence. Intimate partner abuse is now a crime in all states, and most states have laws that require some type of mandatory reporting of domestic violence (1). Therefore, every woman with injuries inflicted by an intimate partner is a crime victim and must be treated with the assumption that the medical record and/or the health care provider may be subpoenaed to appear in court.
Most health practitioners have received little to no formal training in family violence evidence collection and forensic documentation in the medical record. However, some clinicians have received training in evidence collection and forensic documentation pertaining to the sexual assault examination. Sexual assault examination training is helpful in cases where battered women have also been sexually abused by intimate partners. However, it is inadequate for battered women who are not sexually assaulted or for women severely beaten and sexually assaulted.
Receiving a subpoena to appear in court creates much anxiety for many practitioners, who often express concerns that they will make inadequate witnesses and that their assessments, documentation, and clinical findings will be painfully dissected by cross-examining attorneys (2). The purpose of this article is to reduce that anxiety, as well as to improve the quality of patient care, by pro