Genitourinary Medicine and HIV, Imperial College Healthcare NHS Trust, UK
OVERVIEW
Documentation is an essential element of best clinical practice
It should provide another person (or yourself at a future time) a snapshot understanding of what happened at the consultation, in terms of history, who was present, who said what, any physical findings (negative and positive), the management plan (including any concerns) and how any concerns were addressed
The same factors apply to the alleged victim of sexual assault but there also are some specific additional ones to consider
When a patient alleges assault, the best notes possible will help the doctor provide a statement or give evidence in court
All health care professionals are aware that clear and accurate contemporaneous documentation is an essential part of good patient care. Consultations with patients who have experienced physical or sexual assault are no exception. Indeed, it is more likely in such cases that a report or statement will be requested in the future. This is certainly the right time to demonstrate exemplary documentation skills.
You may be asked to provide a report for a criminal injuries compensation claim or a police statement, or you could find yourself in court as a professional witness. In addition, your notes may be requested for disclosure by the police, the Crown Prosecution Service or defence lawyers in civil or criminal cases.
In addition to the general principles of good documentation that you learn in basic training there are some extra skills and points you need to be aware of when documenting your consultation with an alleged victim of assault (see Box 20.1).
It is also important that you make a contemporaneous record of any telephone calls you receive or make regarding your patient and document clearly any advice you give or receive.
The history of the alleged assault is only part of the history taking. It is important to document all aspects just as rigorously, including the standard parts (past medical history, drug history etc.) and anything more specific such as a mental health risk assessment that you carry out in the management of the patient.
Box 20.1 History documentation – dos and don’ts
Do
Write contemporaneously – write notes at the time or immediately afterwards.
Write legibly.
Be objective and stick to the facts – avoid injudicious language.
Explain the concept of confidentiality at the beginning of the consultation and that everything the patient tells you may be disclosable in court.
Remember your role and only ask what you need to know about the assault to enable good management (concentrating on what was done, when, where and by whom).
Record information from third parties as such: ‘A.N. Other, staff nurse on X ward, told me that…’
Record relevant information from the patient verbatim: ‘He punched me twice in the face and my lip split.’
Sign all entries (sign and add your name afterwards in block capitals or with a name stamp).
Date all entries (date and time).
Document who else was present at the time of the consultation (or for a certain part of the consultation), e.g. mother, nurse, interpreter etc.
Document a clear management plan.
Don’t
Leave documentation until the end of your shift.
Think you are a police officer and start taking a detailed history that goes on for pages and pages (this might do the patient a real disservice if it contradicts a report given to the police).
Ask leading questions.
Be selective about what you write down – don’t leave out a detail because you think it might ‘sound bad’ in court (remember you are not an investigator but simply a health care worker).
Write illegibly or use nonapproved abbreviations (you will wish you could read what you wrote at 2 a.m. 2 years later when you are asked for a statement or find yourself being cross-examined by a barrister).
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