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