| Table 1: Information that should be included in the medical record in suspected or alleged cases of wife abuse |
| Who was present during the interview or examination |
| Patient's presenting problem and a detailed description in the patient's words of how the injuries occurred |
| Patient's relevant medical history |
| Detailed description of all physical injuries sustained, including the type of injury, location (in relation to fixed landmarks or standard anatomic regions), length, width, shape, colour, depth, degree of healing and other relevant details (e.g., swelling). If sexual assault is confirmed or suspected, this should also be noted with an indication of the management plan |
| Detailed description of the patient's psychologic demeanour, including gestures, facial expressions and other relevant aspects |
| Child abuse reported by the patient or strongly suspected but not confirmed, and when social services authorities were called |
| A body diagram, if possible, of the location of all visible injuries and scars. The diagram should detail the body parts that were injured, that are functioning normally and that were affected by injury or disease before the incident in question |
| Results of all laboratory and diagnostic tests |
| Medical treatment required |
| Whether hospital admission was required and, if so, the patient's progress during the hospital stay and condition at discharge |
| Any written or verbal information provided to the patient |
| Collection and storage of any physical evidence |
| Photographs, if possible and appropriate, and patient's written consent to be photographed |
| Referrals (e.g., to shelters or counselling) and follow-up plans (e.g., medical appointments) |