Appendix 06_Department of Defense Instruction Number 6400.06.pdf

DoDI 6400.06, August 21, 2007
6.5.4.1. Documentation should be completed by a health care provider who is
authorized to record information in patient records. Documentation should include:
words.
6.5.4.1.1. Patient statements, recorded to accurately reflect the patient’s own
6.5.4.1.2. Relevant history, including current and past incidents of abuse and their
effects on the patient’s health.
6.5.4.1.3. Detailed results of physical examinations, both described in writing and
noted accurately on a body map.
6.5.4.1.4. Photographs when possible and with the consent of the patient.
6.5.4.1.5. Results of any laboratory or diagnostic procedures.
6.5.4.1.6. Results of assessment, intervention, and referrals.
6.5.4.1.7. Patient’s selection of a reporting option.
6.5.4.2. If the patient does not disclose domestic abuse, the HCP shall document in
the record that screening was conducted but the patient disclosed no abuse. If the provider
suspects abuse even though the patient did not so disclose, the provider should document those
concerns in the medical record (e.g., “physical findings are not congruent with history or
description,” “patient presents with indicators of domestic abuse”) and also document any
physical findings suggesting domestic abuse. Notifications in such instances should be made in
accordance with DoD and Military Service policy.
6.6. FAP Responsibilities. In accordance with DoDD 6400.1, DoD 6400.1-M, and DoD
6400.1-M-1 (References (af), (ag), and (ah)), the FAP shall have primary responsibility for
public awareness and education programs in the military community, for ensuring that each
reported incident is assessed for risk of further domestic abuse, for ensuring that victims of
domestic abuse receive a clinical assessment and supportive services, as appropriate, and for
ensuring that domestic abusers receive a clinical assessment, treatment as appropriate, and
ongoing treatment monitoring.
6.6.1. In conducting public awareness and education programs in the military
community, the FAP shall coordinate with local civilian domestic abuse programs and with
national and state civilian domestic abuse public awareness and education programs, modifying
informational materials as appropriate for the military community.
6.6.2. Each incident of domestic abuse shall be assessed for risk whether or not violence
was used in the incident in question. Risk assessment should include at a minimum, the
existence and frequency of the following risk factors:
6.6.2.1. Access to the victim.
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