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Note-Taking About Experienced Violence

Victims of violence do not always have a possibility for a forensic conclusion, therefore it is very important to document injuries or other health disorder symptoms in a patient’s medical record book and to do that in detail. It is not sufficient to record that there is a swell on the head or that there are noticeable bruises on the patient’s hand. It is important to record: which hand, where exactly the bruises (wrist, forearm, upper arm) are, what size, shape is the bruise, and how old are the injuries. All this information is very important when conducting the pre-trial investigation.

Beware that if the patient denies the violence at first and does not want to report it to the police or other services, precise and detailed description about the injuries can become invaluable evidence in trying to prove that she has experienced systemic violence that had an impact on her health disorders.