Documentation in Elder Mistreatment Cases

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Documentation in Elder Mistreatment Cases

• Module 11Nursing Responses to Elder
  MistreatmentAn IAFN Education Course

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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
• Special protection of some medical records
• Drug and alcohol treatment
• Psychiatric records
• HIV records
• 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 patientmake 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)
• Should be labeled as a late entry
• 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
• Narrative description of physical and behavioral
  findings
• 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
• Follow health care setting policy and state law
  for responding to a subpoena
• Clarify type of witness you would be fact and/or
  expert.
• Prepare yourself to testify

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Mrs. Simpsons Case

• Document the following
• What is known about the patients 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
• What happened
• Time, place, mode and frequency
• Whether objects were used
• 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 example
• Where evidence is being stored at the health
  facility
• 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?