Objective clinical intervention protocols
Immediate, evidence-based guidelines for trauma-informed patient assessment, objective charting, and safety planning within busy healthcare environments. Not every provider can help with every problem someone is having, but a full understanding of the situation that led them to come in can help us appropriately refer them to the resources they need so they can receive holistic health care.
Three steps to safety
Private Assessment
Objective Charting
Safety Planning
Conduct screening in a secure, private environment without partners or family members present, utilizing direct, objective questions to establish trust.
Document physical exam findings and behavioral indicators with precise anatomical mapping, avoiding speculative language or subjective summaries.
Implement immediate safety protocols and coordinate directly with specialized advocates before discharging the patient from your care. The most dangerous time for victims is when they decide to leave; creating an appropriate safety plan is imperative to their future safety.
Precise anatomical charting
Medical records serve as vital legal evidence. Document all physical findings with objective, non-judgmental language, noting size, color, and age of injuries.
Utilize standardized body maps for precise anatomical plotting. Quote patient statements directly using quotation marks rather than paraphrasing or interpreting their disclosure. This allows others to be objective when reading your note in the future.
Trauma Informed Care principles
Centers for Disease Control and Prevention (U.S.). Center for Preparedness and Response (2022). 6 Guiding Principles to a Trauma Informed Approach [2022].
Trauma-informed care shifts the focus from “What’s wrong with you?” to “What happened to you?”(22) This can help improve trust with patients and the medical system and even medical adherence.
Essential Interventions/Referrals for all
Psycotherapy
HIV/STI or Contraception prophylaxis
Social Work
Undergoing current or past domestic violence leaves a lasting impact on the physical and mental health of a patient. Referrals to a psychiatrist and therapist for CBT or even EMDR for PTSD are essential.
Many victims of DV will undergo sexual abuse. It is essential to offer this as an option for women even if abuse is not directly disclosed.
Many people who are current victims of DV will need more than medical assistance such as financial or legal help. Social work may be able to refer them to the appropriate services or be able to follow their case further than ED providers.
Safety Planning(23)
Someone they can safely contact if in need of help or a place they can go (a friend's house the abuser does not know or the ER)
Collect evidence. Their testimony is often called into question, so pictures and medical documentation are needed to support the victim's story. Make sure this documentation is in a safe place the abuser won't find it.
Pack a go bag with extra clothes, toiletries, money, prescriptions, and important documents for themselves and their children in case the opportunity to leave arises.
Plan to leave. It is not always possible for them to leave right away, but if they have a plan of when and where they can leave, it can help them prepare. Have them think about best- and worst-case scenarios and the control tactics they might use to keep them.
After leaving, plan to stay safe. Inform schools, work, or create legal safety nets to ensure the abuser can not reach them or their children.
Clinical Guidance
Clinical assessment FAQs
Quick reference answers for common challenges faced during patient screening, charting, and discharge planning.
How do I screen privately?
How do I document quotes?
Always separate the patient from accompanying individuals under the guise of standard clinical procedures like blood pressure checks, routine weight measurements or necessary imaging.
Write exact patient statements in quotation marks. Avoid summarizing phrases like 'patient claims' or 'patient alleges' which imply clinical skepticism.
What if they deny abuse?
When is reporting mandatory?
Respect patient autonomy and build rappor. Document objective physical indicators, offer standard resource materials safely, and leave the door open for future clinical disclosures.
Understand your state's specific laws regarding mandatory reporting for injuries caused by weapons, vulnerable adults, or child abuse exposure.