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Documenting Elder Abuse

VIEWS: 21 PAGES: 5

									Documenting Elder
Chapter Four:



Abuse
       What’s In This Chapter:
       • Importance of Documentation
       • Basic Principles of Documentation
       • Sample Body Chart




Ch.4: Documenting Elder Abuse                29
IMPORTANCE OF DOCUMENTATION
Documenting the details of abuse and/or neglect and information
on a senior’s situation can be an important part of the intervention
process. This information can help the senior and the service
provider to determine if the abuse is escalating and will assist
other service providers who become part of the support process
for the senior. In addition, it may also serve as evidence if
criminal charges for the abuse are laid.

BASIC PRINCIPLES OF DOCUMENTATION
Documentation involves recording only that information which
you know for certain. Avoid subjective data and be sure to record
a client’s comments verbatim. For instance, instead of stating
“Mr. Tilley is not being fed nutritious food”, record that “Mr.
Tilley said that his ‘son never brings him anything healthy to
eat.’”

Where possible, a thorough documentation of a suspected case of
elder abuse or neglect should include the following details when
they are available:

•        General information such as the senior’s name, address, phone
         number, gender, and language spoken
•        Dates and times of your contact(s) with the senior and your
         observations
•        Senior’s physical and mental health status and apparent
         functional capability
•        Senior’s emotional status
•        The older person’s perceptions of their own social situation;
         health status; physical needs; and relationship with family,
         friends, and extended social network

    30                                    Ch.4: Documenting Elder Abuse
•   Names of others in contact with the senior (such as family
    members, other service providers, etc.)
•   Living arrangements of the elderly person
•   Senior’s appearance in terms of hygiene, climate-appropriate
    clothing, body language, etc.
•   Non-physical signs of abuse and/or neglect such as broken
    health aids (glasses, dentures, etc.), torn clothing, etc.
•   Physical signs of abuse, including information on the size,
    pattern, severity, and location of injuries. (Note: This may be
    done on a body chart such as the one found on the next page.)1

Footnote:
1. Body chart courtesy of: Family Violence Prevention Initiative,
Nova Scotia. Elder Abuse: Procedures Manual for a Co-
ordinated Response. Nova Scotia. 1996




Ch.4: Documenting Elder Abuse                                  31
SAMPLE BODY CHART FOR
DOCUMENTATION OF PHYSICAL ABUSE
1. Hand and Finger Marks
2. Bruises
3. Bites
4. Welts
5. Burns
6. Abrasions
7. Scratches
8. Swelling
9. Lacerations




32                         Ch.4: Documenting Elder Abuse
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