Identifying domestic violence requires basic knowledge of the different types of violence and their effects. Various forms and tools can help you ask about and make entries on violence. Use the forms systematically to gather preliminary information and document violence in order to ensure the client’s legal protection. Documenting violence is important because it can also help the client in legal proceedings, for example. Make entries and documentation related to violence in accordance with your organisation’s guidelines.
Use the tool developed for recognising digital violence to assess the digital violence experienced by adult clients and to support intervention. The form was created for use in shelters, but all professionals can use it in their work.
Work with the victim of violence to draw up a written safety plan to help them feel more in control of their situation. Only give the victim a copy if it is safe.
Fill out the form for reporting harassment and persecution if the client has experienced harassment or persecution.
Use the violence screening and assessment form when assessing a client’s life situation. Follow the instructions for completing the form to ensure high-quality documentation. In health and social services, the risk of domestic and family violence should be assessed systematically. Only a small proportion of victims disclose their experiences of violence on their own initiative. Therefore, as a professional, you should ask directly about experiences of violence in order to identify domestic and family violence. Use the guidance on asking about domestic violence and encountering victims as support during the interview.
- Domestic violence screening and assessment form (in Finnish)
- Guidance on asking about domestic violence and encountering victims
Instructions for completing the form
- It is not safe to ask about violence when a potential perpetrator, a person close to the perpetrator, or other clients or patients are present. Never give the form to the client to complete independently or take home.
- The inquiry begins with the screening questions.
- If the client answers YES to screening questions 2 or 3, proceed with the assessment questions and ask the client to assess their situation using the form. Based on this information, assess the necessary interventions.
- If the client answers YES to screening question 4, refer them, where appropriate, to services intended for perpetrators of violence in accordance with local guidelines. In this case, there is no need to continue completing the form.
About the form
THL developed the form in cooperation with the Central Finland Health Care District. Today, the form is available electronically in some client and patient information systems under the title Väkivaltakokemusten arvio (Assessment of experiences of violence).
The risk assessment form is used to assess whether a client is at increased risk of becoming a victim of serious intimate partner violence. Completing the form is one component of the MARAC approach. The information obtained is used to plan measures to improve the victim’s safety in a multi-agency working group.
PAKE form and body maps:
Instructions for using the PAKE form
The PAKE form may be completed by either a nurse or a physician. The information recorded on the form can be used, among other purposes, when filing a police report, to describe injuries and the circumstances of the assault during police interviews, and as a basis for a medical statement. A medical statement is often the most important piece of evidence in assault cases during court proceedings.
Objectives of the PAKE form
- To ensure that the patient's injuries and other information related to the assault are documented carefully and comprehensively.
- To serve as a checklist to ensure that all information relevant to potential legal proceedings is collected.
- To improve the comprehensive care of the assaulted person and ensure continuity of care.
- To strengthen the legal protection of the assaulted person in potential criminal proceedings by carefully documenting the details of the incident and the resulting injuries.
- To draw particular attention to intimate partner violence.
- To enhance cooperation among healthcare providers, social services, the police, and judicial authorities.
- To provide the patient with information about available support services.
Encountering and interviewing an assaulted patient using the PAKE form
Before the interview:
- Arrange for an interpreter if necessary.
During the interview:
- Use the PAKE form as a guide and structure for the interview.
- Speak with the patient in private.
- Ask directly about violence and be mindful of the possibility of sexual violence.
- Allow the patient to describe what happened in their own words. Ask clarifying questions if necessary.
- Clearly state that violence is unacceptable.
- Be aware that the patient's possible intoxication, acute stress reaction, shock, or trauma-related responses may make the interview more challenging. Also consider the potential effects of a head injury on the patient's ability to communicate and describe events.
Other measures:
- When carrying out examinations and procedures, explain to the patient what is being done and why.
- Read more about the forensic medical examination of violent crimes (in Finnish).
- If the patient has experienced intimate partner violence, you must assess the risk of repeated and severe violence. You can use the MARAK risk assessment form for this purpose.
MARAC risk assessment form
Read more about encountering a person who has experienced intimate partner violence
Read more about risk assessment
Recording information in the PAKE form
- Complete the PAKE form for all patients who have experienced assault, regardless of whether they have filed or intend to file a police report. Careful documentation helps ensure the patient's legal protection in potential criminal proceedings, which may begin even years later.
- Record background information based on the patient's account. Clearly indicate if information concerning the events is based on a source other than the patient. This may occur, for example, if the patient does not remember the events or is unable to communicate them.
- Mark injuries on the body chart using the symbols provided on the PAKE form. Number each injury and record its size in centimetres as well as the type of injury. Document all observed injuries, including those that are minor or appear unrelated to the reported incident. This helps provide a comprehensive account of the circumstances for potential legal proceedings.
- Use clear and standardised terminology when recording information, as the PAKE form may also be used by other authorities.
- If the patient refuses examination partially or completely, indicate on the body chart which areas were not examined. The absence of injuries may also have legal significance.
- Update the body chart as necessary throughout the patient's course of care.
- Ensure that the PAKE form is completed in full, even if you were not the person who originally started it.
Recording in the patient information system
You can use the PAKE form when documenting the examination of an assaulted patient in the patient information system. When making entries, consider the following:
1. Record the patient’s background information
- Describe how and with whom the patient arrived at the care unit.
- Record any first aid given at the scene (see the emergency care report).
- Document whether the police were present and whether a police report has been filed.
2. Record a description of the incident
- The time and place of the incident as precisely as possible.
- The perpetrator of the violence and their relationship to the patient. The number of perpetrators, their gender, and nationality.
- The manner of violence and any threats made. Describe how the violence was carried out, which parts of the body were targeted, and how many times. Also describe any instruments or weapons used. Describe the victim’s position in relation to the perpetrator during the act or acts.
3. Describe the patient’s current condition
- Record the time the examination was carried out.
- Describe the patient’s physical condition (e.g., pregnancy, reduced mobility, as well as the level of intoxication and its impact on functional ability).
- Describe the patient’s mental state (note any possible shock reaction and intoxication).
- Mention any use of drugs or medications reported by the patient.
- Describe the injuries found in the patient in detail, including their measurements. Record the type of injury as well as its length, width, depth, diameter, age, shape, and direction. Use the body chart to assist in describing the injuries. If there are multiple injuries, you may refer in the text to the body chart and photographs. Also record injuries that do not require treatment.
4. In your documentation, address the following:
- Were the method of violence or the injuries potentially life-threatening?
- Is there any discrepancy between the patient’s history (anamnesis) and the clinical findings, taking into account the mechanism and age of the injuries?
- Is the patient likely to have cosmetic or functional impairments? Indicate if permanent harm cannot yet be assessed.
- Does the patient require sick leave, and if so, for how long?
Photography
Injuries should always be photographed, as photos help illustrate:
- what the patient looked like after the violence
- what kind of visible injuries the patient has sustained
- how the injuries are located on the patient’s body
Instructions for taking photographs:
- Always start by taking an overall photo of the patient.
- Photograph the injuries both before and after cleaning.
- Capture injury areas so that it is clearly visible in the photograph where on the body each injury is located.
- Take close-up photographs of injuries when necessary.
- Include the date and time in the photographs, as well as information about the direction and the specific body area from which the photo was taken.
- Record in the PAKE form how many photographs were taken.
Photographs can be used, for example, in a medical statement prepared for legal purposes, in police investigations, and in possible court proceedings.