Documentation in
Elder Mistreatment
Cases
Module 11
Nursing Responses to Elder Mistreatment
An IAFN Education Course
Learning Objectives
In this module, participants will learn to:
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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
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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
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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
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Nursing standard of practice for health
setting
Documentation policies of health facility
State and federal laws
o Special protection of some medical records
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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
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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
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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 entry
o Indicate time/date when late charting
occurred
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Completeness
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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
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Completeness of documentation also means
fully describing what is done, observed or
heard and what is important to know
Generally includes:
o
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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
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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
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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:
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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. Simpson’s Case
Document the following
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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
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For medical care and examination
For photographs and evidence
collection
For release of information to
others
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Document Patient History
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Description of mistreatment should include:
o What happened
o Time, place, mode and frequency
o Whether objects were used
o 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
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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
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Wound care
Medications and other ordered
treatments
Reporting/referrals
Discharge/care transition actions
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Document Evidence Disposition
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For example
o Where evidence is being stored at
the health facility
o Details of evidence transfer (to
whom, when, how, etc.)
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Closing Assessment
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What have you learned from this
module that you can apply to your
practice setting?
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