Document Appropriately

1. Document in the patient’s medical record that screening has (or has not) occurred. If screening has not occurred, document why.
2. Record if abuse, neglect, or other signs of trafficking are suspected even if the patient denies its occurrence. Document why trafficking is suspected. (i.e., Explanations are not consistent with injuries).
3. If applicable, photographs can be taken of the patient’s injuries for further documentation. Photographs can be valuable as evidence and should be offered to all patients with visible injuries. Written permission to take photographs should be obtained from the patient. Explain that the photographs will become part of the patient’s medical record and can only be released to the police, adult protective services, or prosecutor with their written permission or by court order.
4. Request a social worker to assist in photo documentation in cases of child abuse, vulnerable adult abuse, domestic violence/intimate partner violence, or human trafficking.
5. When taking photographs:
   1. If possible, take photographs before medical treatment is given.
   2. Use a ruler to help assess the size of the injury.
   3. Take at least two pictures of every major trauma area.
   4. Take one full body picture, including face, to link injuries with the patient.
   5. Write the patient’s name, date, the medical record number, and the name of the photographer.
   6. [Insert where the photographs can be safely stored] . Also attach the consent form to the medical record or have the consent scanned into the medical record.