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Application created by
American College of Physicians-
American Society of Internal Medicine

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Content adapted from New York Office for Prevention of Domestic Violence

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Content adapted by:

Christina Mary Nicolaidis, MD, MPH
Assistant Professor of Medicine and Public Health
Oregon Health Sciences University

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Patrick C. Alguire, MD, FACP
Division of Education
American College of Physicians-American Society of Internal Medicine

< Menultgtampquot=String index out of range: unknownabodybrheadhtmlpsubsuptitlealignCENTERLEFThrefsizeBold SeparateLine TB=BB=Font=Align=Indent=ListItemhref=List=Form=Strike Super Sub Underline Region([ Introduction ]

The mnemonic RADAR is a helpful reminder of the steps in diagnosing and managing victims of domestic violence. The links provide examples of interviewing questions, empathic responses, and appropriate first management steps.

Although many women who are victims of domestic violence will not volunteer any information, they will discuss it if asked simple direct questions in a non-judgmental way and in a confidential setting. Some women will not discuss domestic violence even if asked, but posing the question helps women recognize what they are experiencing constitutes abuse and their health care provider cares about it. Asking questions is both diagnostic and educational. This tool is to assist the health care provider in diagnosing and managing victims of domestic abuse as well as educating all women about abuse.

[ Routinely Ask Female Patients ]

Always interview the patient alone.

The suggested interval for asking about domestic violence is:

All new patients, once a year during the routine health maintenance examination
Each trimester during the pregnancy
At any time you suspect domestic violence

Next >[ Ask Direct Questions ]

Preface questions about domestic violence with a normalizing statement such as:

"Because violence is so common in many women's lives, I've begun to ask about it routinely."



This can be followed by questions about

Physical harm: Have you ever been in a relationship where a partner has pushed, slapped, hit or otherwise physically harmed you?

Threats: Has a partner ever threatened to hurt you or your loved ones?

Control: Do you feel that your partner is overly controlling or jealous?

Sometimes it may appear as if your patient has been abused. Bring out your concern in a non-judgmental manner. For example:

"I notice you have a number of bruises; did someone do this to you?"

Many of my patients with symptoms like you describe have experienced abuse or violence.

Please choose 'No' or 'Yes' as the patient's response to any one of the above questions.

Yes No [ When the Patient Answers Yes ]

Validate her experience by uttering statements like:

"You are not alone."

"No one has to live with violence."

"No one deserves to be treated this way."


Encourage her to talk about it by asking questions like:

"Would you like to talk about what has happened to you?"

"How do you feel about it?"

"What would you like to do about this?"


Listen non-judgmentally

This serves both to begin the healing process for the woman and to give you an idea of what kind of referral she may need.

Document It >[ When the Patient Answers No ]

The patient may not be a victim of abuse and it may be appropriate to discontinue this line of inquiry. Even if she answers no, your questions themselves may prompt the patient to rethink her situation or talk to you about abuse at a later time.

However, if your index of suspicion for abuse remains high, you can use the following links to review clinical clues suggestive of abuse:

Physical injury

Mental health

Gynecologic

Obstetric

Poorly understood symptoms

Patient Denies Abuse but Abuse is Strongly Suspected

[ Physical Injury ]

Repeated chronic injuries

Improbable mechanism of injury

Multiple or bilateral injuries

Bruising in proximal central body

Strangle marks

Finger marks, especially on inner soft tissue of legs or arms

Cuts or slashes on hands, wrists

Black eye(s) or lacerations on face

Perforated tympanic membrane

Fractures to forearm, face, or orbital area

Serious head trauma or spinal injury

Human bites or burns in unusual places

< Back[ Mental Health ]

Depression, including attempted suicide

Alcohol and/or other substance abuse

Anxiety disorders

Eating disorders

Acute psychotic episodes

Decreased concentration

Sleep disturbances

[ Gynecologic ]

Pain and fear during examination

Poor contraceptive compliance or sexually transmitted disease, including HIV

Recurrent urinary tract infections

Chronic pelvic pain

Irregular vaginal bleeding

Sexual dysfunction

[ Obstetric ]

Note: Domestic violence often escalates during pregnancy

Pre-term delivery, placental separation, or low birth-weight infant

Spontaneous abortions

Late or sporadic prenatal care

Hyperemesis or poor nutrition

Partner dictates whether or not patient breast-feeds

[ Poorly Understood Symptoms ]

Chronic pain

Fatigue/decreased energy

Irritable bowel syndrome

Palpitations or fainting with no cardiac abnormality

Recurrent sinus infections or dental problems (related to repeated facial trauma)

[ Patient Denies Suspected Abuse ]

Don't accuse the patient of lying.

Document your opinion.

Let the patient know there are resources available should she pursue such options in the future.

Make a follow up appointment to see her.

[ Document Your Findings ]

Record a description of the abuse as she has described it to you. Use the specific name of the assailant if possible. Record all pertinent physical and emotional findings. For example, you may document, "Patient appears frightened." Use a body map to supplement the written record. Document an opinion if the injuries were consistent with the patient's explanation. Finally, document what counseling and resources were provided. To protect patient safety, do not list where the patient intends to go.

If the patient denies abuse but your suspicion remains high, document your suspicions.

Assess Safety >[ Assess Patient Safety ]

Find out if she is afraid to go home. Has there been an increase in frequency or severity of violence? Have there been threats of homicide or suicide? Have there been threats to her children? Is there a gun present?

A validated Danger Assessment Tool is available at: http://www.son.jhmi.edu/research/ CNR/homicide/DANGER.htm

Options & Referrals >[ Review Options and Referrals ]

If the patient is in immediate danger, find out if there is someone with whom she can stay. Does she need immediate access to a shelter? Offer her the opportunity of a private phone to make a call. If she does not need immediate assistance, offer information about hotlines and resources in the community. Since it may be dangerous for her to take this information home, do not insist.

Make a follow up appointment to see the patient. Make it clear you want to see the patient again, whether or not she follows your recommendations.

References

The National Domestic Violence Hotline: 1-800-799-7233 (1 800 799-SAFE)

To find resources near you: http://www.ncadv.org/ resources/state.htm

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