Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package

3.3. Documenting GBV

3.3.1 Why should health care providers document gender-based violence?

  • For the health professional’s legal issues:Health care providers have a professional obligation to record the details of any consultation with a patient. The notes should reflect what was said (by the patient) and what was seen and done (by the health care provider) and be kept in confidentiality.
  • For the patient’s legal issues:Medical records can be used in court as evidence, for example in criminal proceedings or child custody proceedings. Documenting the health consequences may help the court with its decision-making, as well as provide information about past and present violence. Lack of coordination between health care providers and police/prosecutors can result in evidence getting lost. To this end, it is critical that health care providers understand thelinks between forensic medicine and criminal justice in order to facilitate women’s access to the criminal justice system.
  •  For good clinical care:Documentation can alert other health care providers, who later attend the patient, to her experiences of GBV and thereby assist them in providing appropriate follow-up care (adapted from Warshaw/Ganley 1996, WHO 2003).

3.3.2  Recording and classifying injuries

Health care professionals should carefully describe any injuries assessed. The description should include the type and number of injuries, as well as their location, using a body map. In case a survivor does not disclose, health care professionals should note whether the injuries are compatible with her explanations. This may help clarifying the situation at a future visit and provide documentation in case she decides to pursue legal action (Warshaw/Ganley 1996).

Interpretation of injuriesfor medico-legal purposes is a complex and challenging matter. In practice, clinicians and pathologists are often being asked by police, courts or lawyers to determine the age of an injury, how it was produced or the amount of force required to produce the injury. This requires proven expertise on the part of the practitioners performing it, based on continuing education, exposure to peer review, and quality assurance. Without accurate documentation and expert interpretation of injuries, conclusions on how injuries occurred might be seriously flawed. Therefore, health care professionals who are not trained in the interpretation of injuries should

  • document injuries, using standard terminology as provided in WHO 2003 (i.e. abrasions, bruises, lacerations, incisions, stab wounds or gunshot wounds) and
  •  refer the task of injury interpretation to a forensic specialist (WHO 2003).

Refer to WHO 2003 for more information on the standard terminology for classifying wounds and the main features of each category (section 4.5.2), as well as for a list of violent acts and their most probable associated pattern of injury (section 4.5.4).

3.3.3How and what should be documented?

Mechanisms for documenting consultations include hand-written notes, diagrams, body charts and photography (WHO 2003). Through the entire process of documentation, health care professionals should ensure the patient’s informed consent.

In some countries, health care authorities provide standard documentation forms, the use of which may be obligatory. A WHO sample form for recording consultations with survivors of sexual violence, which may be used as it stands, or can be adapted to meet local needs and circumstances is included in Annex 8. Refer to the training package (part II, module 7) for an example of a documentation form from Austria.

In cases of sexual violence, documentation should include the following (WHO 2003):

  • demographic information (i.e. name, age, sex);
  • consents obtained;
  • history (i.e. general medical and gynaecological history);
  • an account of the assault;
  • results of the physical examination;
  • tests and their results;
  • treatment plan;
  • medications given or prescribed;
  • patient education; and
  •  referrals given.

Photography is an important tool that should be used by all health care providers – specialized and non-specialized in forensic medicine - to document injuries resulting from GBV, as photos are important evidence in possible future criminal proceedings instituted against the perpetrator. When using photography, it is however important to keep in mind that photos may supplement, not replace, the other methods of recording findings mentioned above (WHO 2003). For more information on the use of photography, see box 19.

Box 19: Checklist for using photography to document findings

Source: WHO 2003

Box 20: Documenting cases of sexual abuse: a check-list for health workers

The following check-list is intended to assist health workers to develop their documentation skills:

  • Record the extent of the physical examination conducted and all “normal” or relevant negative findings.
  • Document all pertinent information accurately and legibly.
  • Notes and diagrams should be created during the consultation; this is likely to be far more accurate than if created from memory.
  • Notes should not be altered unless this is clearly identified as a later addition or alteration. Deletions should be scored through once and signed, and not erased completely.
  • Ensure that the notes are accurate; deficiencies may cast doubts over the quality of the assessment.
  • Use the survivors own words in quotes, whenever possible. This is preferable to writing down your own interpretation of the statements made. For example, write “My husband hit me with a bat” instead of “Patient has been battered.”
  • Use neutral language, such as “Ms Smith says…” rather than “The patient alleges.”
  • Do not exclude information that is extraneous to the medical facts, such as “It was my fault he hit me, because…” or “I deserved to be hit because I was…”
  • When documenting referrals, the names, addresses or phone numbers of shelters given to the patient should not be noted, in the interest of the patient’s safety.

Source: WHO 2003, Warshaw et al 1996

3.3.4 Forensic examinations

A forensic examination is defined as “medical examination conducted in the knowledge of the possibility of judicial proceedings in the future requiring medical opinion.” The primary aim of a forensic examination is to collect evidence that may help prove or disprove a link between individuals and/or between individuals and objects or places (WHO 2003).

In all cases involving GBV, where a criminal offence has been committed, as in any other criminal investigation, the following principles for specimen collection should be strictly adhered to:

  • collect carefully, avoiding contamination;
  • collect specimens as early as possible; 72 hours after the assault the value of evidentiary material decreases dramatically;
  • label all specimens accurately;
  • dry all wet specimens;
  • ensure specimens are secure and tamper proof;
  • maintain continuity; and
  • document details of all collection and handling procedures (WHO 2003).

Health care workers should be aware of the capabilities and requirements of their forensic laboratory; there is no point collecting specimens that cannot be tested (WHO 2003).

For a list of forensic specimens that are typically of interest in cases of sexual violence, together with notes on appropriate collection techniques and comments on their relevance, refer to WHO 2003, section 5.2.

3.3.5 Providing evidence in court

Health care professionals may be called upon to give evidence, either in the form of a written report or as an expert witness in a court of law. Therefore, they would be expected to (WHO 1999, cited in WHO 2003):

  • be readily available;
  • be familiar with the basic principles and practice of the legal system and obligations of those within the system, especially their own and those of the police, as it applies to their jurisdiction;
  • make sound clinical observations, which will form the basis of reasonable assessment and measured expert opinion; and
  • reliably collect samples from victims of crime (the proper analysis of forensic samples will provide results which may be used as evidence in an investigation and prosecution).

At the same time, health care practitioners should be aware of the following pitfalls and potential problem areas:

  • providing opinions which are at the edge of, or beyond, the expertise of the witness;
  • providing opinions that are based on false assumptions or incomplete facts;
  • providing opinions based on incomplete or inadequate scientific or medical analysis; and
  • providing opinions which are biased, consciously or unconsciously, in favour of one side or the other in proceedings (WHO 2003).

When writing reports or giving evidence in court, it is paramount that health care professionals should aim to convey the truth of what they saw and concluded in an impartial way, and ensure that a balanced interpretation of the findings is given (WHO 2003). Refer to table 11 for guiding principles for writing reports and giving evidence.

Table 11: Providing evidence in sexual violence cases: guiding principles for health professionals

Health care professionals providing medico-legal services to survivors of GBV should undergo training in such matters. In the absence of specific training in medico legal aspects of service provision, health professionals are advised to confine their service delivery to the health component and defer from offering an opinion. Under such circumstances, the court can seek the assistance of an expert to provide the necessary interpretation of the observations (WHO 2003).

3.3.6 Storage and access to patient records and information

Patient records and information are strictly confidential. All health care providers have a professional, legal and ethical duty to maintain and respect patient confidentiality and autonomy. Records and information should not be disclosed to anyone except those directly involved in the case or as required by local, state and national statutes (American College of Emergency Physicians 1999, cited in WHO 2003).

All patient records (and any specimens) should be stored in a safe place. Biological evidence usually needs to be refrigerated or frozen; check with your laboratory regarding the specific storage requirements for biological specimens (WHO 2003).