1.8 Medical History

Medical History

Medical History.

  • The medical professional takes a medical history for diagnosis and treatment.
  • The medical professional gathers information about the type of contact involving the patient, the timing of the abuse and any symptoms that they may be experiencing.
  • If the patient discloses information about the abuse during their medical evaluation, the provider must document the information in the medical report, preferably in the patient’s own words as a direct quote.
  • Include allergies, medications, recreational drug use, immunization status and medical/surgical history.
  • For sexually active patients, note the last consensual intercourse, pregnancy history and contraception usage.
  • Include a history of consensual sex and prior abuse/assault.
  • Depending on the patient’s age, it may be appropriate to obtain a medical history from both the caregiver and the patient. Asking the patient to briefly explain what happened ensures that their issues are addressed.
Office on Violence Against Women. (2013)