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Suspected Domestic Violence and Abuse (1.2.7)

Suspected Domestic Violence and Abuse (1.2.7) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.7


UW HEALTH CLINICAL POLICY 1
Policy Title: Suspected Domestic Violence and Abuse
Policy Number: 1.2.7
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: June 8, 2016

I. PURPOSE

To establish consistent standards of practice for the process of accurately identifying, intervening and
documenting suspected Domestic Abuse and Domestic Violence.

II. DEFINITIONS

Domestic Abuse: means any of the follow ing engaged in by an adult person against his or her spouse or
former spouse, against an adult w ith w hom the person resides or formerly resided or against an adult w ith
w hom the person has a child in common:
ξ Intentional infliction of physical pain, physical injury or illness
ξ Intentional impairment of physical condition
ξ First, second, or third degree sexual assault
ξ A physical act that may cause the other person to reasonably fear that the conduct described
above w ill imminently occur.

Domestic Violence: (also know n as Intimate Partner Violence) is an ongoing pattern of coercive behaviors
(physical, sexual, psychological) in action or by threat used by a person to gain and maintain pow er and
control over another person. Generally several forms of abuse may be used in combination.

III. POLICY ELEMENTS

UW Health encourages screening of patients suspected to be victims of Domestic Abuse and Domestic
Violence and provides supportive services and referrals w henever needed. UW Health recognizes that
Domestic Abuse and Domestic Violence may affect anyone regardless of age, race, gender, ethnicity,
socioeconomic status, relationship, and sexual orientation. In addition, see UWHC policy #4.44, Guidelines
for Evaluation and Treatment of Patients Reporting Sexual Assault, for information related to the
assessment and treatment of adult patients reporting a sexual assault.

IV. PROCEDURE

A. Indicators of Domestic Abuse and Domestic Violence
i. Physical indicators, behavioral indicators and family indicators do not in themselves imply abuse.
How ever, the presence of these indicators may be clues to ask more questions of the patient about
possible abuse. It is also important to consider that a lack of physical indicators does not imply that
Domestic Abuse and/or Domestic Violence are not present.
a. Physical Indicators: alcohol/substance abuse; injuries indicative of assault such as
bruises, broken bones, burns, lacerations; signs of strangulation; repetitive emergency
room visits or hospital admissions; repeat or chronic injuries, and/or multiple sites of injury
b. Behavioral Indicators: anger, confusion or disorientation; fear, w ithdraw al; dependence on
partner for f inances, transportation, medical care
c. Family Indicators: aggressive behavior such as threats, insults, or harassment tow ard the
injured person; conflicting accounts of the circumstances leading to the injury; the injured
party not allow ed to speak for herself/himself or allow ed to be interview ed only in the
presence of the partner; indifference, anger or blaming the injured person for the injury;
previous history of abuse; unw illingness or reluctance to comply w ith service providers in
planning for provision of immediate and follow -up care
B. Routine Screening
i. Routine universal screening for Domestic Abuse and Domestic Violence is strongly encouraged in
ambulatory settings.
ii. Adult patients w ho are seen in inpatient settings and in Emergency Department (ED) settings w ill
be screened for Domestic Abuse and Domestic Violence at every admission.
iii. Routine screening should be performed by health care personnel w ho have been trained in
Domestic Abuse and Domestic Violence screening and are know ledgeable about interventions and



UW HEALTH CLINICAL POLICY 2
Policy Title: Suspected Domestic Violence and Abuse
Policy Number: 1.2.7

referrals. Health care personnel may use appropriate screening tools as needed.
iv. It is strongly recommended that routine screening occur in private w henever possible.
v. If routine screening is negative and there are indicators of abuse or violence present refer the
patient to community resources as appropriate (refer to IV.G. below ).
vi. If routine screening results in a positive f inding of domestic abuse and/or domestic violence, assess
the patient’s immediate safety, determine if a mandatory report is required (refer to IV.D. below ),
and refer the patient to community resources as appropriate (refer to IV.G. below ).
a. If the patient appears to be in immediate danger, the primary treating provider should call
Security if located at the University Hospital, American Family Children’s Hospital, or The
American Center, or call law enforcement at all other locations.
C. Interview ing Suspected Victims
i. If there is suspicion of Domestic Abuse and/or Domestic Violence, an appropriate physical exam as
w ell as laboratory, radiology, and/or other tests, should be completed by properly trained health
care personnel, being sensitive that abuse may have occurred.
ii. Interview the patient in private.
D. Reporting Requirements
i. Domestic Abuse and/or Domestic Violence reporting is voluntary and requires the patient's express
permission except under certain conditions (refer to IV.D.v.below ).
ii. Reporting to law enforcement, w ithout the victim’s consent, can further endanger victims. Respect
a patient’s right not to disclose Domestic Abuse and/or Domestic Violence or to refuse intervention
w hen the patient believes such action is not in his or her best interest.
a. If a patient refuses to report to law enforcement, and the injuries are not reportable per
Mandatory Reporting requirements below , health care personnel are encouraged to
document all f indings in the patient’s medical record as w ell as the fact that resources
w ere offered to the patient, but the patient refused.
iii. Health care personnel w ill assist any patient w ho w ishes to contact law enforcement to report
domestic violence.
iv. Health care personnel should inform patients about the process of reporting, being honest about
the limitations of confidentiality in their role as mandatory reporters.
v. Mandated Reporters under this policy (nurses, nurse midw ives, nurse practitioners, APNPs,
physicians, physician assistants, anesthesiologist assistants, perfusionists, respiratory care
practitioners, physical therapists, physical therapist assistants, podiatrists, dieticians, athletic
trainers, occupational therapists, occupational therapy assistants, psychologists) must report “the
patient’s name and the type of w ound or burn injury involved” to the local police department or
county sheriff ’s off ice for the area w here the treatment is received if any of the follow ing are present
(refer to the HIPAA and Law Enforcement Guidelines for more information about broader reporting
obligations):
a. Gunshot w ounds unless the w ound appears to have occurred at least 30 days prior to
treatment.
b. All other w ounds and qualif ied burns if the required reporter has "reasonable cause to
believe" the w ound or qualif ied burn occurred "as a result of a crime". Qualif ied burns are
second or third degree burns to at least 5% of the body or inhalation of superheated air
resulting in edema of the larynx or a burn to the upper respiratory tract.
c. Generally, w ounds that are deliberately inflicted by others or are the result of gross
negligence are reportable.
vi. A report does not need to be made if there has been a previous report made or if the patient is
accompanied by a law enforcement off icer at the time of treatment.
vii. Anyone w ho makes a report is presumed to be doing so in good faith and is immune from all civil
and criminal liability that may result from the report.
E. Documentation
i. Documentation in the medical record should address: assessment, treatment, referral(s), and other
activity specif ic to this episode of care. No legal liability is incurred as a result of recording medical
facts, expert medical opinion, or a patient’s statement.
ii. Careful documentation is important. Reports of abuse should be clear, concise, and objective.
a. History
1. Written history should include: w ho caused the injuries, how the injuries
occurred, and if the injuries are consistent w ith the patient explanation of the
cause or suggestive of other causes. Avoid extraneous information (i.e.,



UW HEALTH CLINICAL POLICY 3
Policy Title: Suspected Domestic Violence and Abuse
Policy Number: 1.2.7

circumstances leading up to the injury). A nurse may document consistency of an
injury based upon prior experience and confidence in making that particular
judgement.
2. Preface patient statements w ith the phrase “patient states…” (i.e., “Patient states
she w as kicked in the face by her husband, punched in the abdomen tw o times
w ith a f ist and threatened by him w ith a loaded gun.”).
b. Physical
1. Be as complete and descriptive as possible. Utilize a body map as appropriate
and indicate location and description of physical trauma (i.e., “A 3-cm sw ollen
ecchymotic area on the left cheek consistent w ith a w ound from a punch. X-ray
show s fracture of the nasal bone sustained from incident of reported domestic
abuse”).
2. Preserve physical evidence (i.e., preserve stained or torn garment evidence
using care not to contaminate evidence, etc.) w hen applicable for possible
referral to law enforcement off icial and/or legal proceedings. If a sexual assault
has occurred, refer to UWHC policy #4.44, Guidelines for Evaluation and
Treatment of Patients Reporting Sexual Assault.
3. Orders for appropriate laboratory and radiology studies related to the physical
examination.
F. Special Considerations
i. Adolescents (ages 13-17)
a. Universal and regular screening of all adolescents, aged 13 and older, for teen dating
violence by health care personnel trained in Domestic Abuse and Domestic Violence
Screening is encouraged.
b. Teen dating violence shares many qualities of Domestic Abuse and Domestic Violence in
adults, but should be assessed differently due to differences in stages of development,
social environment, and relationship dynamics.
ii. Child Abuse
a. Screening for Domestic Violence and Domestic Abuse may provide information that
indicates child abuse or neglect.
b. If children (under 18 years of age) are at risk or injured, or have been abused or neglected
in the context of domestic violence and abuse, refer to UW Health clinical policy #1.2.4,
Suspected Child Abuse and Neglect.
iii. Use of an Interpreter
a. Appropriate interpreter services should be utilized by health care providers w hen
screening or examining cases of suspected Domestic Violence and Domestic Abuse if the
patient is unable to communicate w ith the health care provider (i.e. English as a second
language, limited English proficient, deaf and hard-of-hearing).
b. A patient’s family member, friend, or acquaintance should not be utilized as an interpreter
(refer to UW Health clinical policy #3.3.4, Interpreter Services and/or Language
Assistance).
iv. Disabled, Elderly, At-Risk Adults
a. Disabled adults, elder adults, and at-risk/vulnerable adults may be victims of domestic
violence.
b. Refer to UW Health clinical policy #1.2.5, Suspected Elder Adult and Adult-At Risk Abuse
and Neglect.
G. Referral
i. Offer appropriate hospital and community resource referrals (refer to Patient Resources Social
Services Quick Resource Guide and/or contact Social Work). Alw ays consider that the person may
not be ready to take action at this time. He/she may take action w hen he/she feels it may be
possible w ithout endangering his/her life.
ii. Health care providers should collaborate w ith other members of the health care team (e.g. social
w ork) regarding further assessment, education, safety planning, referrals and reporting.
iii. Social Work/Patient Resources can assist w ith referrals to appropriate agencies as necessary. If
there is an immediate need, contact law enforcement.
H. Accounting of Disclosures.
i. Reports of gunshot w ounds, burns, other injuries and Domestic Abuse to the appropriate
authorities must be documented using Quick Disclosure in Health Link. Refer to UWHC policy



UW HEALTH CLINICAL POLICY 4
Policy Title: Suspected Domestic Violence and Abuse
Policy Number: 1.2.7

#6.23, Accounting of Protected Health Information Disclosures; UWMF policy, Accounting of
Disclosure Policy and Guideline.
I. Questions regarding the interpretation of this policy should be directed to the Legal Department. Questions
regarding how to screen/interview patients should be directed to Patient Resources (for ambulatory
settings) or Social Work Services (for inpatient/ED settings).
V. COORDINATION

Author: Manager, Social Work and Spiritual Care Services
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: UW Health Legal Department; Patient Resources; MD, Emergency Medicine; MD, Pediatric and
Adolescent Medicine; RN, Pediatric Emergency Services; Nurse Case Manager, Emergency Services ;
Director, Nursing Quality and Safety
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: May 16, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC policy #4.44, Guidelines for Evaluation and Treatment of Patients Reporting Sexual Assault
UW Health clinical policy #3.3.4, Interpreter Services and/or Language Assistance
UWHC policy #6.23, Accounting of Protected Health Information Disclosures
UWMF policy, Accounting of Disclosure Policy and Guideline
Wisconsin Statutes section 255.40 – Reporting of Wounds and Burn Injuries
ACOG Committee Opinion. No. 518: Intimate partner violence. Obstet Gynecol. 2012; 119 (2 Pt 1): 412-417.
Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate partner violence surveillance: uniform
definitions and recommended data elements, version 2.0. Atlanta, GA: National Center for Injury Prevention
and Control, Centers for Disease Control and Prevention; 2015.
Cutter-Wilson E, Richmond T. Understanding teen dating violence: practical screening and intervention
strategies for pediatric and adolescent healthcare providers. Curr Opin Pediatr. 2011; 23(4): 379-383.
Moyer V. Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive
Services Task Force recommendation statement. Ann Intern Med. 2013; 158(6): 478-486.
Wisconsin Department of Children and Families. Domestic violence handbook. Madison, WI: Division of
Safety and Performance; 2010.
Patient Resources Social Services Quick Resource Guide
https://uconnect.w isc.edu/depts/uw mf/patient-resources/social-services-quick-resource-guide-/
HIPAA and Law Enforcement Guidelines

VIII. REVIEW DETAILS
Version: Original
Next Revision Due: June 2019
Formerly Know n as: Hospital Administrative policy #4.52; MF policy, Suspected Domestic Violence and
Abuse