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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 33
"Documenting Elder Abuse"