Document

Record or document any evidence that may be helpful, including physical evidence and any verbal comments. If at all possible, it is recommended to use direct quotes from the patient when documenting the conversation.

If you report the abusive situation due to the mandatory reporting laws in your state, document a case number in your notes if the state provides one.

Consider asking the patient if you can photograph visible injuries, if possible, or make sure to describe orofacial injuries in detail. It is helpful to hold something up to document the extent of the injuries (e.g., if intraoral lesions, place the probe beside it to document how big the lesion is).

Finally, use neutral language in your documentation. Instead of “alleges,” use the word “reports.” Words with negative connotations can be used against the victim by defense counsel (alleges, refuses, etc.). This detailed information could be very beneficial information if the victim decides to pursue any legal action against the perpetrator. Also, let the victim know that your documents may be subpoenaed if a legal case is initiated.

Sample Documentation Language

(to be used in addition to your normal dental progress notes):

Patient reports physical abuse by significant other on {insert date}. Pt states "he pushed me up against the wall, grabbed me around the neck and punched me in the face." A contusion noted to left side of face, round, light purple in color. Intraorally, bilateral lacerations in healing stages on buccal mucosa and patient reports biting self when being grabbed. Extra and Intra-oral photographs taken after approval from patient. Referrals provided for local IPV services and patient took local shelter business card. Patient was asked if she would like to report incident to police. Patient declines reporting at this time.

**Add report number if your state qualifies for mandatory reporting, such as: “Report made to APS. Report number 65432. Patient informed of APS report.”

Key parts: Reports (instead of alleges), Declines (instead of refuses), and direct quote from patient.