Fifty-four clinicians (42 GPs and 12 PNs) took part in semi-structured telephone interviews. Demographics of participants are reported in Table 1. This study focused on interviewees’ responses about documenting as this illuminates the current organisational and attitudinal barriers faced by general practice clinicians managing DVA in families. Themes identified were knowledge and attitudes about documenting DVA in families; the role of the EPR; and tensions between the different roles of the EPR.
Knowledge and attitudes regarding documentation
Participants described various methods of documenting DVA and child safeguarding in the EPR from national codes to free-text entries (Box 1). Many clinicians were unconfident in documenting DVA. This is consistent with only half of the clinicians having any experience of DVA, few having any DVA training, and that there is no national guidance on which codes should be used. Nine clinicians (six GPs and three nurses) admitted that they did not know how to document DVA. One nurse said that recording DVA should be the doctor’s role:
‘I’d have to speak to the doctors to, you know, work out how, what we would do about that [the case in the vignette], whether that was something that would need to go on the children’s notes, in which case really they [the doctor] should put that on.’
(PN 07, female, age 45–54 years)
Box 1. Electronic mechanisms used by general practice clinicians for documenting domestic violence and abuse in families with children
| Coding mechanisms | Examples |
|---|
| Read Codesa within the EPR |
Mainly use child safeguarding Read Codes: ‘26 different codes’ Little use of existing domestic violence and abuse Read Codes Read Code as ‘cause for concern’ Read Code as ‘depression’ Practice has own template of Read Codes
|
| Hidden alerts within EPR software |
|
| Messaging systems |
|
| Free text |
|
Clinicians decisions’ about documenting DVA were shaped by attitudes about naming different forms of DVA and when to document these in the notes:
‘Violence in the home I think is one [Read Code] we use, if we know that Mum has been hit and presumably we could use that because he [Danny in vignette] has punched her, so that, that’s the commonest one I tend to end up using but it’s not so easy if it’s just name calling or emotional abuse.’
(GP 25, female, 45–54 years)
This was reflected in a wide variety of responses to how to document the DVA in the vignette:
‘I suppose at the end if, you know, it [the case] was as clear as this [the vignette], then my, my problem title [Read Code] would be “domestic violence.”’
(GP 37, female, 45–54 years)
‘I think with this lady [Sarah in vignette] I would, I might, I’d probably put the problem title [Read Code] more to do with “depression”… as a clinical diagnosis but in the … comment section or in the history section [free text] … I would be writing what I saw as significant issues.’
(GP 42, male, 45–54 years)
Clinicians were more confident about how to document child safeguarding. This is unsurprising, given that all responders reported some mandatory child safeguarding training which often covers how to document, including which codes to use. Despite this, six clinicians were not aware of a practice-wide documenting policy for child safeguarding and nine admitted to ‘doing their own thing’:
‘To be honest we haven’t had this discussion, I’m not actually sure we have a practice policy.’
(GP 01, female, 35–44 years)
Where practices did have policies, there was wide variation at a national and local level. In one study site, a GP stated that they used and regularly updated the national codes:
‘Yes we have certain codes that we use and then these are updated from social services.’
(GP 26, female, 25–34 years)
At another practice in the same area, they reported developing their own practice policy with no input from Children’s Services.
Even when clinicians were confident in their knowledge about documenting, inconsistency still occurred because of the different roles of the EPR.
Role of the EPR
Four roles of the EPR were described when documenting DVA in families with children: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record.
A legal document
Some clinicians discussed documenting in the victim’s EPR to make a legal record of injuries and abuse. These clinicians described the EPR as a ‘factual record’ (GP 13, female, 45–54 years). Their strategies for documenting DVA reflected this:
‘I would record the, the reason for, for presenting [using a code] and then in a sort of free text … I would record the actual nature of this disclosure, what the disclosure was, whether there were any hard confirmatory signs of physical injury, you know, sort of bruising, size and shape, location, that sort of thing, and then I would record my sort of immediate actions and what my sort of next steps would be in terms of where I was going to take it in terms of follow-up.’
(GP 34, female, 25–34 years)
Some of these clinicians had concerns about documenting in other family members’ EPRs events for which they only had the victim’s account:
‘So I would be reluctant to put in somebody’s notes that they were perpetrating domestic violence because of course it’s not proven, but I would perhaps put a code in: “... see wife, spouse’s, girlfriend, boyfriend, whatever’s notes”.’
(GP 31, male, 45–54 years)
‘It’s [the DVA] alleged, I wouldn’t put anything in there [the perpetrator’s EPR].’
(GP 19, male, 25–34 years)
These clinicians would only record in other family members’ EPRs if they had corroborating evidence of a child safeguarding issue:
‘Certainly if there is documented evidence that there is a [safeguarding] case, it’s very difficult when there’s a suspicion, not a case.’
(GP 15, female, age not given)
Continuity of care
Many of the clinicians described using the EPR to aid relational continuity of care (sometimes using code words to remind themselves of patient history), or informational continuity of care (often using free-text notes in case the patient saw a different clinician):
‘If I suspected I sometimes sort of do put something in the notes as a reminder to myself, I’ll perhaps put three question marks besides, you know, marital problems ??? … as a little remind to myself about them.’
(GP 41, female, 55–64 years)
‘It would be … about the level of domestic abuse, some key features, what the patient said, what the patient’s problems are, what their outcomes that they want, what the plan is for the action … so if anybody does read it, I’m off for a weekend or off ill or off on holiday, somebody else can pick up the case and coordinate.’
(GP 40, male, 45–54 years)
Information sharing for safety
Nearly all clinicians recognised that DVA was a child safeguarding issue and as such should be recorded in the children’s EPR (although some clinicians required ‘evidence’ to do so). Clinicians discussed documenting DVA as a first step in information sharing to highlight child safeguarding issues within the practice team, recognising other clinicians might see different family members:
‘The difficulty with safeguarding is, is making sure that, you know, information is there so that people can access it … so that no matter who goes into the records people know that there are safeguarding issues, because that’s ultimately what our job is as GPs, is to safeguard the children and the family and obviously the mum of the children.’
(GP 21, female, 45–54 years)
Just under half (n = 26) of the clinicians identified the importance of documenting DVA in children’s EPRs. A further 13 clinicians said they would also document in the perpetrator’s EPR. GPs discussed sharing this information to address related behaviours in the perpetrator such as mental health or alcohol consumption, or to provide an opportunity to challenge behaviour:
‘If we’re aware of it [DVA] on his record then next time he came in about his drinking you could, well we would ask, you know, what kind of problems is this having, are you having any problems in your relationship, those types of things?’
(GP 22, female, 55–64 years)
‘In some ways it’s quite a useful challenge to say “well look, you know, we’ve been advised about this issue, we record it on all the patients’ records because that is our practice” by way of communication and if he didn’t like it that’s his problem … Making him aware that we’re all aware and that he’s not going to get away with it.’
(GP 12, male, 55–64 years)
Thirteen clinicians explicitly stated, however, they would not document DVA in the perpetrator’s EPR. For some, this was because it was ‘only’ an allegation (see above), but for many it was because of concerns about escalating abuse if the perpetrator discovered the disclosure in their EPR:
‘I wouldn’t [document in perpetrator’s EPR] because that partner [the perpetrator] has, has access to the notes [has the right to view his EPR] and, and the, the woman hasn’t actually given you permission to do that, and that could cause, you know, could cause lots of problems and could put her at more risk.’
(GP 28, female, 55–64 years)
A patient-owned record
No clinician discussed the EPR as a mechanism to empower patients or families experiencing DVA. Clinicians were aware that patients could request to see their EPR or their children’s EPR. However, patient ownership and control of what is recorded was a difficult process:
‘ [If] she doesn’t want me to record it, I don’t record it because obviously she would not want me … that’s a very difficult situation, I can do all in my power to try and persuade her, I can give the statistics how if it’s physical but a lot of people do end up losing their lives … If the children are affected I can actually override her I feel and contact the child safeguarding teams. If there are no children involved and it’s just a woman, I, I don’t think I can override her wishes unless she had a mental health problem and I felt she could be sectioned but I can’t really, all I, it’s very difficult.’
(GP 41, male, 45–54 years)
In contrast, another GP was aware that patients can access their notes, but this did not affect her decision to document as she felt the EPR is the property of the NHS:
‘You know, my view is that the patient record is, it doesn’t really belong to them [the patient], it belongs to the NHS and so it’s still OK for me to document that stuff and if they [the perpetrator] look, well that’s one of those things isn’t it? You know, it may offend them but if it’s honest and factual then there isn’t really a lot that they can do in terms of arguing, arguing over it.’
(GP 03, female, 35–44 years)
Three GPs felt that patient access to online records was not an issue as the EPR represents a ‘factual’ (GP13, female, 45–54 years) account. Five were extremely concerned, however, that patient ownership of their own records actually increased the potential for a coercive partner to get access to the abused partner’s EPR:
‘It is difficult because, you know, in theory you would only have access to your own information or, or whatever; however, if you’re in a controlling relationship, you know, it’s not going to be very difficult for somebody inappropriate to get hold of a, you know, your login details or whatever, so I certainly see that as a, a risk to individuals.’
(GP 36, female, 45–54 years)
Tensions among the different roles of the EPR
Multiple roles of the EPR resulted in uncertainty regarding the best way to document. The main tension identified was that between confidentiality to protect the abused parent and information sharing for child safety.
Clinicians were worried that the EPR might be seen accidentally by the perpetrator, resulting in an escalation of DVA for both the abused parent and children:
‘We think there’s a danger in them [the perpetrator] accessing those records and, and thereby making the victims more vulnerable.’
(GP 36, female, 45–54 years)
This led some clinicians to develop strategies to hide DVA documentation using code words and linking records using numbers:
‘What we would do is we would put it on [the perpetrator’s EPR] as a “cause for concern” [code] but what we’d often do, simply because sometimes patients can be left in a room with a computer on and their records up, would be to [write] “See record [and then give a record number]”. So you’d just put like a “cause for concern” code on and then you’d perhaps put a code through to Sarah’s records rather than putting everything down.’
(GP 22, female, 55–64 years)
Clinicians’ concerns about confidentiality increased as the number of family members involved multiplied.
Another tension occurred regarding the clinicians’ uses of the EPR versus the patients’ access to the EPR:
‘I think we write some things in some people’s records that they shouldn’t read and that’s on a very individual basis and … most people can read their records but I think in some situations they, there’s some things people shouldn’t read, and we’re putting it on there to warn other people and, and that’s to the benefit of the patient.’
(GP 10, male, 35–44 years)
Therefore, some clinicians discussed sharing information while avoiding documenting in the notes by sending e-mails or private messages within the practice:
‘I don’t think I’d put anything on the patient’s records but I would discuss with the other clinical staff about the situation, so just let them know or, so that would probably consist of sending an e-mail round on our Outlook NHS e-mail or internal e-mail to the other clinicians, saying please could you look out for this patient’s notes?’
(GP 33, female, 25–34 years)
