Medical-Legal Injury Documentation Note (Assault/IPV)

Medical-Legal Injury Documentation Note (Assault/IPV)

(Use neutral, objective language throughout. Attribute patient history with "patient reports/states..." Avoid speculative statements about mechanism, weapon, force, trajectory, or bruise age. Do not make legal conclusions or credibility judgments. Use direct quotes for key patient statements.)

Header Fields

Date: [Date]    Start Time: [Start time]    End Time: [End time]

Facility/Site: [Facility name]    Department/Service: [Department]

Author: [Author name, credentials]

Patient: [Patient name, DOB, MRN]

Identity Verified: [Verification method / deferred—reason]

Persons Present: [Names and roles of all persons present] (Indicate clearly if patient was interviewed and examined alone, and when this occurred.)

Chaperone: [Name and role / none]

Advocate Present: [Name and agency / none]

Interpreter: [Language, modality, interpreter ID / none]

Record Sensitivity Flag: [Restricted/sensitive per policy / standard] (If photos taken, note storage location and access restrictions.)

Consent, Confidentiality, and Reporting

• Consent—Medical evaluation and treatment: [Consented / declined / partial—scope and limitations]
• Consent—Photography: [Consented—face included / consented—body surface only / declined] (Specify permitted body regions.)
• Consent—Evidence/sample collection: [Consented / declined / not indicated]
• Consent—Release of information: [None / parties authorized and scope]

Confidentiality Limits Explained: [Yes / no] (Include mandatory reporting categories per jurisdiction.)

Safe Contact Preferences: [Preferred contact method, safe times, voicemail/text preferences] (Document if follow-up contact could increase risk.)

Mandatory Reporting: [Not triggered / triggered—report required]

• Report Made: [Yes / no—reason if not made]
• Agency Notified: [Agency name, contact, reference number]
• Date/Time of Report: [Date/time]

(If no photography, evidence collection, or reporting occurred, explicitly state this with brief context.)

Chief Concern and Brief Medical Context

Chief Concern: [Chief concern as stated]

Pertinent Medical Context: [Anticoagulants/antiplatelets, bleeding disorders, pregnancy status, tetanus status, allergies, other relevant factors] (If clinically relevant status is unknown, specify "unknown—not assessed" or "unknown—patient unable/unwilling to answer.")

Pain Score: [0–10]    Functional Limitations: [Functional limitations relevant to injuries]

Source of History

Historian(s): [Patient / EMS / police / family / prior records]

Limitations Affecting Reliability: [None / intoxication / head injury / dissociation / language barrier / time elapsed / interruptions / other]

Time Anchors: Assault reported on [date/time]; presentation at [date/time]; examination began at [date/time].

History of Reported Event

(Write in neutral narrative with embedded timestamps and clear attribution throughout.)

[Setting and context as reported, with date/time markers]. [Relationship of assailant to patient as reported].

[Reported actions and exposures] (Use direct quotes for key statements, threats, or strangulation descriptions.)

[Post-event activities affecting evidence: bathing, clothing changes, eating/drinking, oral hygiene, wound cleaning, medications taken]

Symptoms Since Event: [Symptoms reported since event] (If patient is uncertain about loss of consciousness, document "patient uncertain regarding LOC." Do not infer intent or force beyond what patient explicitly reported.)

Review of Systems (Targeted)

• Neuro: [Positive—details / negative / not assessed]
• HEENT: [Positive—details / negative / not assessed]
• Neck/ENT: [Positive—details / negative / not assessed] (Especially important if strangulation reported.)
• Respiratory: [Positive—details / negative / not assessed]
• CV: [Positive—details / negative / not assessed]
• GI: [Positive—details / negative / not assessed]
• MSK: [Positive—details / negative / not assessed]
• Skin: [Positive—details / negative / not assessed]
• GU/GYN: [Assessed—details / not clinically indicated / not disclosed] (Include only if clinically indicated or disclosed.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2] at [time recorded]

General Appearance: [Observable demeanor] (Describe without judgment.)

• Head/Face/Scalp: [Findings and relevant negatives]
• Eyes: [Findings and relevant negatives]
• Ears/Nose/Mouth: [Findings and relevant negatives]
• Neck: [Findings and relevant negatives] (Document presence or absence of bruising, petechiae, swelling, tenderness, voice/airway findings.)
• Chest: [Findings and relevant negatives]
• Abdomen: [Findings and relevant negatives]
• Back: [Findings and relevant negatives]
• Extremities: [Findings by region and laterality with ROM and neurovascular status]
• Hands/Nails: [Findings including defensive injuries]
• Neurologic: [Orientation, speech, gait, focal deficits] (Include if head injury or strangulation concerns.)

(Document tenderness even without visible findings.)

Injury Documentation

(Create an entry for each distinct injury. Use precise anatomic descriptions and measurements. Do not estimate bruise age from color.)

INJ-01: [Anatomic location with laterality and landmarks]

• Injury Type: [Abrasion / contusion / laceration / incision / puncture / avulsion / bite wound / hematoma / erythema / petechiae]
• Shape/Pattern: [Shape and pattern description] (Describe without concluding mechanism.)
• Color: [Color description] (Note variegation if present; do not estimate age.)
• Size: [Length × width in cm; depth if measurable]
• Borders/Surrounding Tissue: [Well-demarcated / diffuse; swelling/warmth/drainage present or absent]
• Palpation Findings: [Tenderness, crepitus, fluctuance; distal neurovascular status]
• Functional Impact: [ROM limitation / grip strength / gait impairment / none]
• Body Map Reference: [Diagram region and plotted label]
• Photo Reference: [PHOTO-## / none]

INJ-02: [Anatomic location with laterality and landmarks]

• (Repeat fields as above for each additional injury.)

Overall Injury Summary: Injuries documented as INJ-01 through INJ-[##]; photographed as PHOTO-01 through PHOTO-[##]. (Note if any injuries were treated prior to examination. If no visible injuries identified after targeted exam, state "No visible injury identified on examination" and document any tenderness or symptoms.)

Body Map

[Reference standardized anterior/posterior body diagrams with each injury plotted by Injury ID and clear laterality] (If no injuries identified, state "no injuries plotted.")

Photo Documentation

• Consent Reaffirmed Prior to Photos: [Yes / no / not applicable]
• Equipment: [Device type], flash [on / off], forensic scale [used / not used]

Photo Log

(Document each photo in sequence.)

PHOTO-01

• Date/Time: [Date/time]
• Body Region: [Region]
• Injury ID(s) Shown: [INJ-##]
• View: [Orientation / close-up]
• Scale: [Yes / no]
• Photographer: [Name, credentials]

PHOTO-02

• (Repeat for each additional photo.)

Storage: [Storage location and access restrictions]

(If no photographs taken, document why: equipment not available / patient declined / emergent care priorities.)

Evidence Collection

• Consent for Evidence Collection: [Obtained / declined / not indicated]

Items Collected

ITEM-01

• Description: [Item description]
• Source: [Source location]
• Condition: [Wet / dry / soiled—description]
• Packaging: [Packaging type, label identifiers, seal method]
• Collector: [Name, role]
• Collection Date/Time: [Date/time]

ITEM-02

• (Repeat for each additional item.)

Chain of Custody

• Transfer 1: Released by [name/role] to [name/agency/badge #] on [date/time], seal intact [Y/N]
• Transfer 2: [Additional transfers as needed]

(If no evidence collected, state: not indicated / not available / patient declined.)

Diagnostics and Treatment

• Imaging: [Studies and key results]
• Laboratory: [Tests and key results]
• Procedures/Wound Care: [Wound care provided]
• Medications: [Medications administered with dose/route]
• Consultations: [Consultations obtained]

Assessment

• [Diagnosis 1]
• [Diagnosis 2]
• [Additional diagnoses as applicable]

Findings documented as above; patient-reported history recorded. (Avoid definitive causation statements beyond clinical scope.)

Limitations: [Absence of visible injury does not exclude reported assault. / Bruise color documented descriptively; age estimation not performed. / Examination limited by specific factor.] (Include as applicable.)

Safety Planning and Disposition

• Immediate Safety Assessment: [Safe to return home / unsafe—alternate plan needed / patient uncertain]
• Resources Offered: [Resources provided: advocate contact, hotline, shelter, legal aid, protective order information]
• Follow-Up Plan: [Follow-up instructions and return precautions]
• Disposition: [Discharged to home / shelter / admitted] with [transport plan and accompanying person]

Release of Information

[No information or photographs released at this visit.] (Or if released: Released to [recipient], authorization [obtained / not obtained], mechanism [method], content released [specific items]. Patient counseled that protections may change once information is released outside covered entities.)

Attestation

Author Signature: [Name, credentials]

Forensic Examiner: [Name, role, credentials] (If different from author.)

Documentation Completed: [Date/time] (Note if completion was delayed from encounter.)