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The patient’s responses to questions should be comprehensively documented, using the patient’s own words whenever possible.
Social information, including functional status, the caregiver’s relationship to the patient, and the living situation should also be documented.
Providers should describe the physical exam in detail. Include the general appearance of the patient upon the first arrival in the ED. Potential signs of neglect – including dirty clothing, poor dental hygiene, and untrimmed nails – need to be documented.
For each injury, the ED provider should describe its size, location, stage of healing, and whether it is consistent with the reported mechanism. Using a body diagram / traumagram – which is available as part of many electronic medical records – may increase accuracy when describing findings.
Geriatric-Injury Documentation Tool (Geri-ODT) is a useful tool to ensure comprehensive, appropriate documentation of injuries and other physical findings in older adult patients. It includes a body diagram. Research on the development of the Geri-IDT has been published.
Photo Evidence
ED providers should photograph physical findings and add these photographs to the medical chart when practical and if approved by hospital administration. Patient’s consent should be obtained when possible. These images may be helpful forensically in the future.
Providers should use a standardized approach for this photography.
General Principles
- Include identifiable information
- Use a ruler and color guide
- 90° angle to the injury
- Hold the ruler 1-2” off the skin
- Include patient identification in photographs
Click to download two PowerPoint slide decks (Addressing Elder Abuse the Problem, and Addressing Elder Abuse the Solution) that are designed for anyone interested in raising awareness about the problem of elder abuse in their health care facility.
A Comprehensive Photography Protocol may be helpful to ensure optimal photographs. Research on the development of this protocol has been published. The protocol is also available for download.
Click here for References.