High-Yield Rules

**Rule 1**: Interview patient ALONE before screening or asking about safety.
Screening: Universal for all women of reproductive age & during all prenatal visits (USPSTF). c
Highest Risk Period for Homicide: Immediately after leaving or attempting to leave the relationship.

Clinical “Red Flags”

Behavior: Partner insists on answering, hovers, or refuses to leave; delayed presentation for trauma.
PE: Injuries in multiple stages of healing, central distribution (face, neck, breasts, abdomen), defensive forearm bruises.
Somatic/Psych: Chronic pelvic pain, IBS, unexplained headaches, PTSD, MDD, SI, recurrent STIs.

Next Best Step Algorithm

Isolate & Screen: Separate pt tactfully; ask direct, non-judgmental questions (“Do you feel safe at home?”).
Assess Immediate Danger: Inquire about firearms at home, history of strangulation/choking, or homicide threats.
Validate: Empathize (“You are not alone; this is not your fault”).
Safety Planning: Formulate escape plan (emergency bag with ID/cash, safe shelter/contacts, crisis hotline).

Legal & Ethical Decision Rules (Exam Traps)

Scenario	Mandatory Action
Competent Adult	DO NOT call police without consent. Respect autonomy; offer safety plan.
Child Involved	MANDATORY: Report immediately to CPS.
Elderly / Vulnerable Adult	MANDATORY: Report immediately to APS.
Gunshot / Stab Wound	MANDATORY: Report to law enforcement per state statute.

What NOT to Do (High-Yield Distractors)

Do NOT recommend couples therapy / marital counseling (provokes retaliatory abuse).
Do NOT pressure/force pt to leave the relationship immediately.
Do NOT breach confidentiality to report adult IPV to police against their will (escalates lethal danger).