Documenting in the Medical Record

Write what the patient has said about the situation in their own words.
Record differing stories from the patient and the caregiver, after interviewing separately.
Do a complete physical exam, noting possible signs of abuse as well as general hygiene, appearance, demeanor, and level of functionality.
Help document the situation with drawings or photographs, which can be powerful. See “evidence” section of domestic abuse website for instructions.
Document medication history/compliance, and physical
or laboratory evidence of over or under dosing.
Do a mental status exam. You may ask for a psych consult if you have reservations about the patient’s cognitive ability to make decisions about possible interventions (see Ethics).
Note who reported the case and to whom, what form was
filled out, and where and when it was sent. [Complete HIPAA tracking form.]
Social worker or you to make a safety plan with the patient, educate about abuse, and provide referral APS hotline information - document.
If the patient lacks capacity, social worker to make arrangements with Adult Protective Services re: placement, protection orders, conservatorship, etc. – document.
Make a follow-up appointment

Is It Abuse?

Some normal aging and chronic medical conditions may mimic abuse:

skin fragility

acquired or drug induced bleeding tendencies

osteoporosis

balance problems, orthostatic hypotension

decreased taste and thirst sensation

decreased nutrient absorption

decreased healing ability due to age, diabetes or arteriosclerosis

incontinence -> skin breakdown

pelvic organ prolapse, atrophic vaginitis

For complete discussion see Arch Pathol Lab Med 2006;130:1290-1296
PMID 16948513