Documentation of Abuse

Well-documented medical records must be maintained by the physician and should include the following information:

      Name of the injured person.

      Location of the injured person.

      Extent and character of the person’s injuries.

      Identity of the person the injured person alleges inflicted the wounds, other injuries, assault, or abusive conduct upon the injured person.

      Description of the abusive event or description of the major complaints in the injured person’s own words, whenever possible.

      Medical and relevant social history of the injured person.

      Map of the location of the injuries on the victim’s body documented at the time of the health care service.

      A copy of the law enforcement reporting form.