Session 5: Documentation

Objectives

• Know how to document in a safe, confidential manner.
• Explain the importance of correct documentation.
• Understand how to correctly fill out the medical exam form.

Presentation

Facilitator guide

Activities

NOTE for something.

Video

The videos include a fictional story of rape or intimate partner violence that may be distressing, difficult or even re-traumatizing for some viewers to watch and listen to. This video is for educational purposes to show participants how to conduct a history and interview about an incident of rape or intimate partner violence.

5. Documentation guidelines

Video by International Rescue Committee and UCLA – Center for International Medicine. https://www.rescue.org/. 
Please see https://iawg.net/resources/clinical-care-for-sexual-assault-survivors for the complete clinical care for sexual assault survivors (CCSAS) multimedia tool.

Video by International Rescue Committee and UCLA – Center for International Medicine. https://www.rescue.org/. 
Please see https://iawg.net/resources/clinical-care-for-sexual-assault-survivors for the complete clinical care for sexual assault survivors (CCSAS) multimedia tool.

Participant handouts

Key messages

• Document the description of the incident in a clear, objective, non-judgmental way
• Document injuries clearly, precisely and systematically
• Documentation must be safely, securely stored

Required supplies & materials

• Projector, Laptop
• Pen and blank paper workbook for each participant
• Printouts of sample medical history and examination forms and pictograms for the activity

Further resources for facilitators (Optional)

• WHO (2020) Clinical management of rape and intimate partner violence survivors Developing protocols for use in humanitarian settings, pg 20-21