DOMESTIC AND FAMILY ABUSE AND VIOLENCE (DFAV)
ACTION PLAN
Refer to the HealthPathways DFAV page for comprehensive information on Risk 
Assessment and Safety Planning, including screening tools and local DFAV services:
Hunter New England Health Pathways Username: hnehealth Password: p1thw1ys

RE: <PtFullName>
DOB: <PtDoB>
Gender	<PtSex>	Pronouns	<Pronouns>	
Address 	<PtAddress>                                                                          	Phone	<PtPhoneMob>	
Does the patient identify as:	       Aboriginal	<Does the patient identify as Aboriginal?>	Torres Strait Islander	<Does the patient identify as Torres Strait Islander?>	Culturally and/or Linguistically Diverse	<Does the patient identify as culturally and/or linguistically diverse?>	LGBTIQ+	<Does the patient identify as LGBTIQ+>	
Does the patient need an interpreter to communicate?	<Does the patient need an interpreter to communicate?>	If yes, specify language	<If yes, specify language>	
Children’s Name and Age	<Children's name and age>	
Name of Other Party (Person Using Violence)	<Name of other party (person using violence)>	Relationship to Patient	<Relationship to patient>	
Emergency Contact	<Emergency Contact>	Other care plan:
e.g. MHCP / GPMP / TCA	<Other care plan eg MHCP/GPMP/TCA?>	
GP Name / Practice	<DrDetails>			

Disclosure of DFAV
Enter reason for visit: DSWB
If the answers to any questions above is yes, respond as follows:
Yes to Questions 1 - 2
Call the Local Coordination Point or NSW Domestic Violence Line if out of hours. 
Local Coordination Point
1800 938 227
NSW Domestic Violence Line
1800 65 64 63
Yes to Questions 3 – 9
Send this plan to the Local Coordination Point via secure messaging (Medical Objects).
 
If yes to any, please safety plan before patient leaves appointment.

If no to the risk assessment questions, safety planning may be left to the follow up appointment.	This risk assessment will help identify patients most at risk of lethality or serious harm

If no to the below, patients will still experience significant distress due to DFAV.

Patient’s value support from their GP with non-judgemental listening, validation, and reassurance that domestic violence is not their fault. 		
	Risk Assessment		
	1.	Does the patient feel unsafe to go home?		<Risk Assessment: Does the patient feel unsafe to go home?>	
	2.	Does the patient feel that they, or their children, are at immediate risk of harm?	<Does the patient feel that they, or their children, are at immediate risk of harm?>	
	3.	Has the perpetrator attempted to strangle, choke, or asphyxiate patient?
As per clinical guidelines please refer patient to ED with referral letter.	<Has the perpetrator attempted to strangle, choke, or asphyxiate to patient?>	
	4.	Has the perpetrator used or threatened to use a weapon against the patient or their family?	<Has the perpetrator used or threatened to use a weapon against the patient or their family?>	
	5.	Has the perpetrator threatened to kill the patient or their family?	<Has the perpetrator threatened to kill the patient or their family?>	
	6.	Does the perpetrator have known mental illness or a history of drug or alcohol misuse? 	<Does the perpetrator have known mental illness or a history of drug or alcohol misuse?>	
	7.	Is the patient pregnant?		<Is the patient pregnant?	>	
	8.	Has there been physical violence or sexual assault?		<Has there been physical violence or sexual assault?	>	
	9.	Has the patient recently left or is planning to leave?	<Has the patient recently left or is planning to leave?>	
	Additional relevant information		
	<Additional Relevant Information>		
	According to Part 13A of the Crimes (Domestic and Personal Violence) Act 2007, patient consent is not required for information sharing if the practitioner believes the person is at serious threat and that the information sharing is necessary to lessen the threat.		

Follow up Appointment
(Book a double appointment)
Enter reason for visit: DSWB
GP follow up within two weeks. If this isn’t possible, please consider an appointment with a Practice Nurse.	Safety planning is a crucial intervention that saves lives. Plan with your patient how they and their children might escape from home safely and quickly if violence is escalating.	
	Safety Planning	
	Things to consider: 
•	Supportive people and/or organisations, Safe neighbours
•	Escape bag – medication, clothing, important docs, comforter toy for children
•	Safe transport
•	Safe communication
•	Safety of children, Safety of pets	

Patient Plan	
Patient needs	Goals	Management	Referrals	
Identify needs as identified by the patient.	Record the goals agreed to by the patient and GP and any actions the patient will need to take	Treatments, actions and support services to achieve patient goals	DFV is complex and multilayered and requires an interdisciplinary response.	
Information and advice only

Would like to stay in the relationship, but wants the violence to stop

Wants to leave the relationship

Requires an immediate response and crisis accommodation.
	Ensure safety of patient and children

Address DFAV impacts on children’s developmental milestones, particularly speech, language and communication. 

Consider social and emotional difficulties for both adult and child. 	Attend to any injuries 

Refer to Local Coordination Point for triage and on-referral including:
•	Counselling
•	Legal
•	Housing
•	Care coordination
The LCP will provide feedback as to the outcome of the referral via secure messaging

Where a child may be at risk of harm, use the NSW Mandatory Reporter Guide  to determine if a report is required.
If a mandatory report is required. Also report protective behaviours of the parent and any referrals made.	All referrals should be directed to the Local Coordination Point (LCP) for triage and appropriate on-referral. 

When making referral to LCP, provide informatipn about cultural needs on Page 1.

Consider referral to a speech pathologist for children for speech, language and communication assessment.
	
Safe time and day to call	<Safe time and day to call>	Has the patient consented to referral to the Local Coordination Point?	<Has the patient consented to referral to the Local Coordination Point?>	
Preferred ontact number and / or email
	<Preferred contact number and/or email?>	Copy of the plan provided to the Local Coordination Point	<Copy of the plan provided to the Local Coordination Point>	
Alternate contact number and / or email 	<Alternate contact number and / or email>	Is it safe to leave a message?	<Is it safe to leave a message?>	
In the event the Local Coordination Point is unable to make contact, does the patient consent to being referred to an alternate service?	<In the event the Local Coordination Point is unable to make contact, does the patient consent to being referred to an alternate service>	
Completing the plan
On completion of the plan, the GP is to record that s/he has discussed with the patient:
•	risk assessment and safety planning,
•	all aspects of the plan and the agreed date for review (Practice Nurse can complete review),
•	referral to the Local Coordination Point for specialist support and care coordination.	Signed consent required

__________________________________________________
Scan back into the patient file and send via secure messaging.
According to Part 13A of the Crimes (Domestic and Personal Violence) Act 2007, patient consent is not required for information sharing if the practitioner believes the person is at serious threat and that information sharing is necessary to lessen the threat.	
Date plan completed	<Date plan completed>	Review date	<Review date>	
	Enter Reason for visit: DSWB	GP follow up within two weeks. If this isn’t possible, please consider an appointment with a Practice Nurse.	
	Review Notes