Bartlett Regional Hospital Domestic Violence Assessment
Bartlett Regional Hospital
سنجش خشونت خانگی بیمارستان بارتلت
DOMESTIC VIOLENCE ASSESSMENT
Date _______________ Patient ID # _________________
Patient Name ____________________________________
Patient pregnant _____ yes _____ no
R= Routinely Screen
"Because violence is so common in peoples' lives‚ I've begun to ask about it routinely."
A=Ask Direct Questions
_____ yes _____ no Are you afraid at home?
_____ yes _____ no Are you in a relationship in whichyou have been hurt or threatened?
_____ yes _____ no Have you ever been hit‚ kicked‚ orpunched by someone close to you?_____ # of times in the past year.
_____ yes _____ no I notice you have a number of bruises; did someone do this toyou?
D=Document Your Findings
Patient report: Patient's description of assault (use patient's own words)
_______________________________________________
_______________________________________________
_____ yes _____ no Domestic Violence confirmed bypatient.
If yes‚ name and relationship of perpetrator:
_______________________________________________
_____ yes _____ no Domestic Violence suspected.State reasons:
_______________________________________________
A=Assess Patient Safety
_____ yes _____ no Is client afraid to go home?
_____ yes _____ no Increase in severity/frequency ofabuse?
_____ yes _____ no Threats of homicide or suicide?
_____ yes _____ no Weapon present?
_____ yes _____ no Do you want police intervention?
R=Review Options and Referrals
_____ yes _____ no Need immediate shelter?
_____ yes _____ no Hotline number/community resources given?
_____ yes _____ no Referred to AWARE staff?
_____ yes _____ no Referred to outside source?
_____ yes _____ no Follow-up appointment made?
Date ___________________
_____ yes _____ no Can patient be called at home?
If no‚ is there a safe number where patient can be reached?
_________________________
Provider Evaluation
_______________________________________________________________
Provider Signature ______________________________
نگاره ای از روبرو و پشت زن هست که یافته های بالینی را برپایه رده بندی زیر در آن مشخص می شود. شامل: کوفتگی، ساییدگی، پارگی، خونریزی، حساسیت به لمس
Check Physical Findings Indicate Where Injury Was Observed
Contusion Abrasion Laceration Bleeding Tenderness
· Head
· Ears
· Nose
· Cheeks
· Mouth
· Neck
· Shoulder
· Arms
· Hands
· Chest
· Back
· Abdomen
· Genitals
· Buttocks
· Legs
· Feet
`_____ yes _____ no Photographs taken? Addressograph
شرح سایت روان سنجی: ابزاری برای ارزیابی آسیب های ناشی از خشونت خانگی است.
اعتبار: مشخص نیست.
چگونگی دستیابی
منبع و ماخذ
Bartlett Regional Hospital Domestic Violence Assessment