1. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package 7. Documentation of GBV 1

2. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Aim of this module To explain why it is necessary to document GBV To provide an overview of the different steps involved in –Recording and classifying injuries –Documenting GBV –Providing medico-legal services –Storing patient data 2

3. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Outlook Importance of documenting GBV Recording and classifying injuries How and what should be documented Forensic examinations Providing evidence in court Storage and access to patient records/info 3

4. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Importance of documenting GBV 4

5. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Uses of documentation Health professional’s legal issues Professional obligation to record details of any consultation with a patient Notes should reflect what patient said, what was seen and done Keep confidential Patient’s legal issues Medical records can be used in court as evidence Documenting health consequences may help court in decision- making and provide info about past/present violence Lack of coordination between healthcare and police/ prosecutors can cause loss of evidence For good clinical care Documentation can alert other health care providers, who may later attend the patient, to her experiences of GBV and thereby assist in providing appropriate follow-up care 5

6. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Recording and classifying injuries 6

7. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Recording and classifying injuries Recording - carefully describe any injuries –Type, number of injuries, and location using a body map –In case a survivor does not disclose, note whether the injuries are compatible with her explanations Interpretation involves determining age of an injury, how it was produced or the amount of force required to produce the injury (for forensic purposes) Without accurate documentation and expert interpretation, conclusions on how injuries occurred might be seriously flawed. 7

8. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Don’t interpret without training Health care professionals who are not trained in interpretation of injuries should –document injuries, using standard terminology as provided in the WHO medico-legal guidelines for victims of sexual violence (i.e. abrasions, bruises, lacerations, incisions, stab wounds or gunshot wounds) –refer the task of injury interpretation to a forensic specialist 8

9. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package How and what should be documented 9

10. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package What to document in cases of sexual violence Information including:  demographic information & patient education  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  referrals given 10

11. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package How to document Hand-written notes Diagrams Body charts Photography –Should be used to document injuries, but not replace other methods of recording –Important evidence for criminal proceedings Checklist for photography Consider the patient Identification Scales Orientation Chain of custody Security Sensitivity H26 H27 H28 11

12. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Forensic examinations 12

13. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Forensic examination “ Medical examination conducted in the knowledge of the possibility of judicial proceedings in the future requiring medical opinion ” Principles for specimen collection: collect carefully, avoiding contamination collect specimens as early as possible (72 hours after assault, value of evidentiary material decreases) label all specimens accurately dry all wet specimens ensure specimens are secure and tamper proof maintain continuity document details of all collection/handling procedures 13

14. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Providing evidence in court 14

15. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package be readily available be familiar with basic principles, practice of the legal system, and obligations make sound clinical observations reliably collect samples from victims of crime Expectations of health care providers 15

16. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Guiding principles Writing reports 1. Explain what you were told and observed. 2. Use precise terminology. 3. Maintain objectivity. 4. Stay within your field of expertise. 5. Distinguish findings and opinions. 6. Detail all specimens collected. 7. Only say or write what you would be prepared to repeat under oath. Giving evidence in court 1. Be prepared. 2. Listen carefully. 3. Speak clearly. 4. Use simple and precise language. 5. Stay within your field of expertise. 6. Separate facts and opinion. 7. Remain impartial. ** Without specific training of medico-legal aspects of service provision, health professionals should not offer an opinion. The court can seek an expert for interpretation of observations. 16

17. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Storage and access to patient data 17

18. Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Storage and access to patient data Professional, legal and ethical duty to maintain and respect patient confidentiality and autonomy. Records/information should not be disclosed to anyone except those directly involved in the case or as required by local, state and national laws. All patient records should be stored in a safe place. Biological evidence usually needs to be refrigerated or frozen; check with your laboratory. 18