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

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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?

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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

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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

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Fundamentals of Documentation

Accuracy Timeliness Completeness Appropriateness

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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

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Example of Improper and Proper Correction of Medical Record

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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

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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

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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

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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

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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

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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

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Document Nursing Interventions

Wound care Medications and other ordered

treatments Reporting/referrals Discharge/care transition actions

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Document Evidence Disposition

For exampleo Where evidence is being stored

at the health facilityo Details of evidence transfer (to

whom, when, how, etc.)

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Closing Assessment

What have you learned from this module that you can apply to your practice setting?

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