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Documentation in Elder
Mistreatment Cases
Module 11
Nursing Responses to Elder MistreatmentAn IAFN Education Course
Learning Objectives
In this module, participants will learn to:
Discuss policies related to documentation in elder mistreatment cases
Discuss fundamentals of medical record documentation
Describe how to communicate findings to appropriate parties in each case, including responses to subpoenas
Describe what to document in the medical record for elder mistreatment cases
2
Questions
What do you currently do in terms of documentation when elder mistreatment is known or suspected? What forms does your practice setting use for documentation in these cases?
What do you currently do in terms of communicating what has been documented with appropriate parties? Are there additional forms your practice setting uses for documentation for these parties?
3
Written Documentation
A hallmark of thorough nursing care includes meticulous documentation in the patient medical record
What is written in the patient medical record has forensic implications
4
Knowledge Foundation
Nursing standard of practice for health setting Documentation policies of health facility State and federal laws
o Special protection of some medical records Drug and alcohol treatment Psychiatric records HIV records
o For initial reporting to the justice system, APS or other agencies
5
Accuracy
Legible Proper grammar and correct spelling Correct information Proper abbreviations Correct patient—make sure record
includes additional identifying information if there are other patients in the health care system with same name
Errors corrected properly
7
Timeliness
Try to chart at the time that care is given
Use of late entry (information added to medical record after initial charting was completed)o Should be labeled as a late entryo Indicate time/date when late charting
occurred
9
Completeness
Consent for care Patient history Exam/assessment findings Evidence deposition Care and contact with patient Reporting and referrals made to
other providers or agencies
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Completeness
Completeness of documentation also means fully describing what is done, observed or heard and what is important to know
Generally includes:o Narrative description of physical and
behavioral findingso Full description of all injuries and forensic
evidence, using written notes, body maps and photo-documentation as appropriate
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Appropriateness
Unless making a diagnosis, describe rather than label behavior
Avoid judgmental terms such as “non-compliant” or “refuses care”
Use health terms, not legal terms
12
Communicating Findings
Look to laws and policies to identify who needs to know what in which cases, procedures for communicating findings, and how to document communication in medical record
If subpoenaed to testify as a witness: o Follow health care setting policy and state law for
responding to a subpoenao Clarify type of witness you would be: fact and/or
expert.o Prepare yourself to testify
13
Mrs. Simpson’s Case
Document the following What is known about the patient’s health status and
presenting injuries (type, size, location and color) Any pertinent statements made by the patient or
others who accompany the patient Any lab or diagnostic procedures that nurses think are
necessary to further assess for mistreatment Additional questions to ask the patient to further
detect or rule out mistreatment Possible strategies to enhance communications with
her, given her speech impairment
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Document Consent
For medical care and examination
For photographs and evidence collection
For release of information to others
15
Document Patient History
Description of mistreatment should include: o What happenedo Time, place, mode and frequencyo Whether objects were usedo Identity of eyewitnesses
Ask patients how they received injuries, even if patient is known to be non-verbal
Verbatim statements
16
Document Physical Assessment
Vital signs, height, weight, general physical appearance, hygiene, demeanor, behavior during the exam and mental status
Additional information from complete physical exam
Description of wounds/and trauma Description of photographs taken and evidence
collected and preserved Inclusion of photographs taken and body maps
with locations of injury and physical trauma
17
Document Nursing Interventions
Wound care Medications and other ordered
treatments Reporting/referrals Discharge/care transition actions
18
Document Evidence Disposition
For exampleo Where evidence is being stored
at the health facilityo Details of evidence transfer (to
whom, when, how, etc.)
19