Proper documentation of the abuse as reported by the victim is a crucial role of the nurse.Evaluate the following data,which include information from the victim,and choose the best documentation by the nurse.A 34-year-old Caucasian arrives at the emergency department with a black right eye;she also is bleeding from the left side of her head.She reports that her boyfriend has been abusing her physically.The nurse performs a history and physical examination and documents her findings.

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It is important to list the name of the abuser,if possible,because a defense strategy is to portray the victim as having more than one partner.Listing the name eliminates any confusion as to who the abuser was.In addition,using accurate medical terminology is crucial.If you are unsure of the proper descriptive terms to use in documentation,simply describe what you see without labeling the injury.Photographs should be taken.Documenting only that the client states that her boyfriend beat her lacks specificity and important details related to the event.In addition,improper medical terminology is used.This type of documentation would be detrimental to the victim's case if she were to pursue legal recourse against the abuser.Documenting only that the client states that her boyfriend hit her in the eye and head lacks specificity and important details related to the event.In addition,improper medical terminology is used.This type of documentation would be detrimental to the victim's case if she were to pursue legal recourse against the abuser.Documenting only that the client reports being abused lacks specificity and important details related to the event.In addition,improper medical terminology is used.This type of documentation would be detrimental to the victim's case if she were to pursue legal recourse against the abuser.

Proper Documentation of the Abuse as Reported by the Victim