case study: documentation
Mr. L is dropped off in the ED by his nephew, who is his caregiver, for evaluation of a fall out of his wheelchair. Mr. L has a bruise surrounding his left eye and several small bruises on both forearms that appeared to be fingertip marks. On initial arrival, before he is changed into a gown, he was wearing dirty, soiled clothes. He is also cachectic-appearing and dehydrated. Mr. L has mild cognitive impairment but he is able to report that his nephew “didn’t feed him much”, “grabbed him,” “screamed at him,” “hit him often,” and “didn’t help him to the bathroom.” Mr. L’s history is documented in his own words.
All findings from his exam are also comprehensively documented using the Geri-IDT, and his appearance at initial arrival into the ED is documented. With Mr. L’s consent, photographs are taken. Several months later, after it has become clear that Mr. L has been a victim of chronic elder abuse and neglect, the district attorney subpoenas the records from his ED visit. The comprehensive documentation of injuries provides critical evidence at trial and helps to convict the nephew and protect Mr. L.
...the quality of the documentation can significantly impact justice
for the protection of a victim.
Complete and accurate documentation is an essential part of the ED’s care of potential victims.
The ED provider should keep in mind that the medical chart may be used for investigation and prosecution.
Therefore, the quality of the documentation can significantly impact justice for the protection of a victim.
Comprehensive documentation is critical.
Learn about the Geriatric-Injury
Photograph the evidence
using a systematic approach.