Development of an Audit Tool to Evaluate the Documentation of Partner Abuse Assessments within a Provincial Emergency Department: An Exploratory Study

Abstract

The aim of this study was to develop a clinically valid and reliable audit tool that evaluates the assessment documentation of females presenting to the emergency department following an assault secondary to partner abuse. A 5-step process informed by a quality improvement approach was used to develop the tool and good inter-rater reliability was achieved. The tool developed has wide utility in services implementing family violence intervention in which nurses have a key role.

Appendix

Item Definitions and Weighting

Question One: Body map

• 0 Map/good quality drawing not used

• 1 Body map/good quality drawing has less than half the known injuries described and recorded/or all injuries recorded but not a full description of the type of injuries

• 2 Body map/good quality drawing used with description of over half the injuries recorded in detail

• 9 Not applicable, no injury that requires a body map.

Question Two: Woman’s pregnancy identified

• 0 No indication in notes that an assessment regarding pregnancy occurred.

• 2 Clear evidence in notes that the pregnancy noted/HCG result noted in notes/or records indicate whether woman is pregnant or not or patient refuses to answer this question

• 9 Not applicable (post-menopausal).

Question Three: Abuser present

• 0 No indication in notes as to the whereabouts of the abuser

• 2 Clear evidence in notes that abuser is/is not in the department or victim refuses to answer this question.

Question Four: Woman afraid of partner

• 0 No indication in notes that this question was assessed

• 1 Notes indicate that the woman is concerned about safety but no indication as to whom she is unsafe with

• 2 Clear evidence in notes that she is/is not afraid of her partner or victim refuses to answer this question.

Question Five: Woman afraid to go home

• 0 No indication in notes that this question was assessed

• 1 Notes indicate that the woman is concerned about her safety but no indication as to where she is unsafe

• 2 Clear evidence in notes that she is/is not concerned about her safety at home or victim refuses to answer this question.

Question Six: Woman identifies that the physical violence has increased in severity

• 0 No indication in notes that this assessment occurred

• 1 Notes indicate that this is not the first act of physical abuse, but does not indicate previous injuries or trend

• 2 Clear evidence in notes of a pattern of increasing/decreasing severity of abuse, or that this is the first episode of abuse or victim refuses to answer this question.

Question Seven: Physical abuse to children identified

• 0 No indication in notes that this assessment occurred

• 1 Notes indicate that children were present in the home but no indication that the risk to the children was assessed

• 2 Clear evidence in notes as to the number of children in the household and that child abuse is/is not present

• 9 Not applicable, no children in the household.

Question Eight: Children witness violence in home

• 0 No indication in notes that this question was addressed

• 1 Notes indicate that children present in the home but no evidence that children witnessing violence was assessed

• 2 Clear evidence in notes as to the number of children in the household and that the children had/had not been present during abusive episodes, or whether children had/had not witnessed violence

• 9 Not applicable, no children in the household.

Question Nine: Threat of homicide

• 0 No indication in notes that this assessment occurred

• 1 Notes indicate threatening behaviour by a person to the victim of abuse

• 2 Clear evidence in notes that there have/have not been any threats of homicide or victim refuses to answer this question.

Question Ten: Threat of suicide

• 0 No indication in notes that this assessment occurred

• 1 Notes indicate previous self-harm attempts in previous medical history/notes indicate suicidal thoughts but no evidence of risk of suicide assessment

• 2 Clear evidence in notes that threat of suicide has been assessed or victim refuses to answer this question.

Question Eleven: Gun in the house

• 0 No indication in notes that this question was addressed

• 2 Clear evidence in the notes that a gun was/was not present in the house or victim refuses to answer this question.

Question Twelve: Alcohol or substance abuse documented

• 0 No indication in notes that this assessment occurred

• 1 Notes indicate a pattern of abuse of either alcohol or drugs

• 2 Clear evidence in notes that a pattern of both alcohol and substance abuse were assessed for or victim refuses to answer this question.

Question Thirteen: Safety plan discussed

• 0 No indication in notes that this was discussed

• 1 Notes indicate that safety identified, but safety plan not documented

• 2 Clear evidence of a long-term safety plan discussed or victim refuses to discuss safety planning.

Question Fourteen: Referrals made appropriately

• 0 No indication in notes that referrals were discussed.

• 1 Notes indicate referrals were made but do not specify to whom, or appear incomplete.

• 2 Clear evidence in notes of appropriate referrals in accordance with risk assessment or victim refuses to discuss referrals.

Question Fifteen: Signature of discharge nurse

• 0 No identification in notes as to who is responsible for documentation, or illegible signature

• 1 Legible signature or printed name but no designation

• 2 Legible signature, printed name, and designation.

Question Sixteen: History

• 0 No indication in the notes of the injuries being documented, no documentation of abuse/an alleged assault being the cause for the injuries at this presentation

• 1 Notes indicate that presenting complaint as an alleged assault, with none of the 4 variables assessed

• 2 Notes indicate that presenting complaint as an alleged assault, with one of the 4 variables assessed

• 3 Notes indicate that presenting complaint as an alleged assault, with two of the 4 variables assessed

• 4 Notes indicate that presenting complaint as an alleged assault, with three of the 4 variables assessed

• 5 Notes indicate that presenting complaint as an alleged assault, and all 4 variables assessed.

The four variables
A	Mechanism of injury identified clearly
B	Perpetrator identified: First and family name or victim refuses to answer question
C	Verbatim quotes used
D	Assault with weapon (e.g., knife, gun, bat), choking, strangulation or smothering in history

Question Seventeen: Examination

Injury descriptions are assessed according to three variables:

Variable Name:	Definition:
Site:	Location of the injuries clearly marked or described
Measurement:	Injuries given accurate dimensions, for example, width, length, diameter
Description:	Must include some of the following: position, depth, shape, age, (Bruise, cut, graze, burn is not sufficient)

Scores are allocated according to the proportion of injuries described well in each domain.

Score	Combination
0	No variable adequately described for any injury
1	Some or all of the variables well described but in less than half of the injuries
2	Any one variable well described in half or more of the injuries
3	Any two variables well described in half or more of the injuries
4	All variables well described in half or more of the injuries
5	Any two variables well described in all injuries and other variable well described in more than half
9	Not applicable (injury not appropriate for description in this detail, e.g., closed head injury without visible injury)