What is the appropriate initial assessment and management for a patient presenting with domestic violence?

Initial Assessment and Management of Domestic Violence

Physicians should routinely ask women direct, specific questions about abuse using validated screening instruments such as HITS, OVAT, STaT, or HARK to identify domestic violence in the clinical setting. 1

Screening Approach

Validated Screening Tools

• HITS (Hurt, Insult, Threaten, Scream): 4-item questionnaire with high sensitivity (86%) and specificity (99%) in English version; can be self-administered or clinician-administered 1, 2
• OVAT (Ongoing Violence Assessment Tool): 4-item version with sensitivity of 93% and specificity of 86% 1
• STaT (Slapped, Threatened, and Throw): 3-item instrument with sensitivity ranging from 62% to 96% 1
• HARK (Humiliation, Afraid, Rape, Kick): 4-item tool with sensitivity of 81% and specificity of 95% 1

Private Assessment

• Conduct screening in a private setting without the potential perpetrator present
• Use direct, specific questions about abuse rather than vague inquiries 1
• Document the patient's own account using direct quotes whenever possible 3

Initial Management Protocol

Immediate Safety Assessment

1. Assess immediate danger and safety concerns
2. Document any immediate safety concerns
3. Develop a safety plan with the patient 3

Documentation Requirements

• Record precise anatomical location, size, shape, and appearance of all injuries 3
• Avoid vague terms and subjective language
• Document patterns of injury, particularly those suggesting implements or squeezing 3
• Note multiple injuries in different stages of healing
• Include photographs when appropriate, ensuring proper chain of custody 3

Intervention Approaches

For women of reproductive age, effective interventions include:

• Counseling on safety behaviors and community resources
• Referrals to community services
• Information cards with resources
• Mentoring support
• Home visits (for some populations) 1

Special Considerations

Children in Domestic Violence Situations

• Approximately 15% of children in clinical settings have been exposed to domestic violence 4
• Child safety questionnaires significantly increase detection of domestic violence (OR = 3.6) 4
• Children's awareness of caregiver harm is sufficient to cause harmful sequelae 5
• Mandatory reporting of child abuse is required in all 50 states 1, 3

Elderly and Vulnerable Adults

• Prevalence of abuse ranges from 2% to 10% 1
• Only 1 in 5 cases are actually reported 1
• Mandatory reporting of elder abuse is required in all 50 states 1
• Be alert for indicators of abuse and institute measures to prevent further abuse 1

Common Pitfalls to Avoid

• Failure to screen: Many cases go undetected without routine screening 6
• Screening in presence of potential abuser: May intimidate victim and prevent disclosure 3
• Incomplete documentation: Records may be subpoenaed if there is prosecution 3
• Breaking confidentiality: Be aware of privacy regulations and state reporting requirements 1
• Treating injuries without addressing underlying abuse: Up to 30% of women presenting to emergency departments with traumatic injuries report domestic violence as the cause 6

Follow-up Care

• Schedule follow-up appointments to monitor safety and healing
• Provide ongoing support and referrals to community resources
• Document all follow-up care and referrals provided 1, 3

Domestic violence screening should be incorporated into routine care, similar to screening for high blood pressure or high cholesterol, as it affects millions of Americans who may deny or refuse to admit they are victims of abuse 7.