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ABUSE, SUSPECTED
Abuse may be suspected in any age group, cultural setting, or environment. The patient may readily report being abused or may fear reporting the abuser. Types of suspected abuse include neglect and physical, sexual, emotional, and psychological abuse.
In most states, nurses are required by law to report signs of abuse in children, older adults, and individuals with disabilities. (See Common signs of neglect and abuse, page 2.) The nurse should use the appropriate channels for the facility and report his or her suspicions to the appropriate administrator and agency. Document suspicions on the appropriate form for the facility or in the nurse’s notes. If the patient is a child, interview the child alone, and try to interview caregivers separately to note inconsistencies with histories. An injunction can be obtained to separate the abuser and the abused, ensuring the patient’s safety until the circumstances can be investigated.
Remember, certain cultural practices that produce bruises or burns, such as coin rubbing in Vietnamese groups, may be mistaken for child maltreatment. Regardless of cultural practices, the judgment of child maltreatment is decided by the department of social services and the health care team. (See The nurse’s role in reporting abuse, page 3.)
Essential Documentation
When documenting, the nurse should record only the facts and be sure to leave out personal opinions and judgments. Record the time and date of the entry. Provide a comprehensive history, noting inconsistencies in histories, evasive answers, delays in treatment, medical attention
sought at other hospitals, and the person caring for the individual during the incident. Document the physical assessment findings using illustrations and photographs as necessary (per police department and social service guidelines). Describe the patient’s response to treatments given. Record the names and departments of people notified within the facility. Provide the names of people notified outside the facility, such as social services, the police department, and welfare agencies. Record any visits by these agencies. Include any teaching or support given.
sought at other hospitals, and the person caring for the individual during the incident. Document the physical assessment findings using illustrations and photographs as necessary (per police department and social service guidelines). Describe the patient’s response to treatments given. Record the names and departments of people notified within the facility. Provide the names of people notified outside the facility, such as social services, the police department, and welfare agencies. Record any visits by these agencies. Include any teaching or support given.
COMMON SIGNS OF NEGLECT AND ABUSE
If the assessment reveals any of the following signs, the nurse should consider neglect or abuse as a possible cause and document the findings. Be sure to notify the appropriate people and agencies.
Neglect
Failure to thrive in infants
Malnutrition
Dehydration
Poor personal hygiene
Inadequate clothing
Severe diaper rash
Injuries from falls
Failure of wounds to heal
Periodontal disease
Infestations, such as scabies, lice, or maggots in a wound
Abuse
Recurrent injuries
Multiple injuries or fractures in various stages of healing
Unexplained bruises, abrasions, burns, bites, damaged or missing teeth, strap or rope marks
Head injuries or bald spots from pulling out hair
Bleeding from body orifices
Genital trauma
Sexually transmitted diseases in children
Pregnancy in young girls or women with physical or mental handicaps
Verbalized accounts of being beaten, slapped, kicked, or involved in sexual activities
Precocious sexual behaviors
Exposure to inappropriately harsh discipline
Exposure to verbal abuse and belittlement
Extreme fear or anxiety
Additional Signs
Mistrust of others
Blunted or flat affect
Depression or mood changes
Social withdrawal
Lack of appropriate peer relationships
Sudden school difficulties, such as poor grades, truancy, or fighting with peers
Nonspecific headaches, stomachaches, or eating and sleeping problems
Clinging behavior directed toward health care providers
Aggressive speech or behavior toward adults
Abusive behavior toward younger children and pets
Runaway behavior
LEGAL CASEBOOKTHE NURSE’S ROLE IN REPORTING ABUSE
Nurses play a crucial role in recognizing and reporting incidents of suspected abuse. While caring for patients, the nurse may note evidence of apparent abuse. If such evidence is found, the nurse must pass the information along to the appropriate authorities. In many states, failure to report actual or suspected abuse constitutes a crime.
Because nurses may hesitate to file an abuse report because of the fear of repercussions, it is important to remember that the Child Abuse Prevention and Treatment Act protects against liability. If the nursing report is bona fide (i.e., filed in good faith), the law protects from any suit filed by an alleged abuser.
Nursing Documentation of Abuse
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ACTIVITIES OF DAILY LIVING
Activities of daily living (ADLs) checklists are standard forms completed on each shift by the nursing staff and, in some cases, the patient performing the activities. After completion, the nurse reviews and signs them. These forms tell the members of the health care team about the patient’s abilities, degree of independence, and special needs so that they can determine the type of assistance each patient requires. Tools that are useful in assessing and documenting ADLs include the Katz index, the Lawton Instrumental Activities of Daily Living Scale, and the Barthel index and scale.
Essential Documentation
The nurse should be sure to include the patient’s name, the date and time of the evaluation, and the nurse’s name and credentials. On the Katz index, the nurse ranks the patient’s ability in six areas:
bathing
dressing
toileting
transferring
continence
feeding
For each ADL, check whether the patient can perform the task independently, needs some help to perform the task, or cannot perform the task without significant help. (See Katz index, page 5.)
The Lawton scale evaluates the patient’s ability to perform complex personal care activities necessary for independent living, such as:
using the telephone
cooking or preparing meals
shopping
doing laundry
managing finances
handling medications
using transportation
doing housework
Rate the patient’s ability to perform these activities using a three-point scale: (1) completely unable to perform task, (2) needs some help, or (3) performs activity independently. (See Lawton Instrumental Activities of Daily Living Scale, page 6.)
ACCUCHARTKATZ INDEX
Below you’ll find a sample of the Katz index, which is used to assess six basic activities of daily living.
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Adapted from Katz, S., et al. “Progress in the Development of the Index of ADL,” The Gerontologist 10(1): 20-30, 1970. © The Gerontological Socity of America. Reproduced (adapted) by permission of the publisher.
ACCUCHARTLAWTON INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE
The Lawton Instrumental Activities of Daily Living Scale evaluates more sophisticated functions—known as instrumental ADLs—than the Katz index. Patients or caregivers can complete the form in 10 to 15 minutes. For each category, circle the item description that most closely resembles the client’s highest functional level (either 0 or 1).
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Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179-186, 1969. Copyright © The Gerontological Society of America. Reproduced (Adapted) by permission of the publisher.
ACCUCHARTBarthel Index
The Barthel index, shown here, is used to assess the patient’s ability to perform 10 ADLs, document findings for other health care team members, and reveal improvement or decline.
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© Adapted with permission from Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel index. Maryland State Medical Journal, 14, 62.
The Barthel index and scale is used to evaluate:
feeding
moving from wheelchair to bed and returning
performing personal hygiene
getting on and off the toilet
bathing
walking on a level surface or propelling a wheelchair
going up and down stairs
dressing and undressing
maintaining bowel continence
controlling the bladder
Score each ADL according to the amount of assistance the patient needs. Over time, results reveal improvement or decline. Another scale, the Barthel self-care rating scale, evaluates function in more detail. (See Barthel index, pages 7 and 8.)
ADVANCE DIRECTIVE
An advance directive is a legal document used as a guideline for the medical care of a patient with an advanced disease or disability who is no longer able to indicate his or her own wishes. Advance directives also include living wills (which instruct the health care provider regarding life-sustaining treatment) and durable powers of attorney for health care (which name another person to act on the patient’s behalf for medical decisions in the event that the patient cannot act for him- or herself).
Because laws vary from state to state, the nurse must be sure to find out how his or her state’s laws apply to nursing practice and to the medical record.
If a patient has previously executed an advance directive, the nurse should request a copy for the chart and make sure the health care provider is aware of it. Many health care facilities routinely make this request a part of admission procedures. (See Advance directive checklist, page 10.)
Essential Documentation
The nurse should document the presence of an advance directive and notify the health care provider. Include the name, address, and telephone number of the person entrusted with decision-making power. The nurse should indicate that he or she has read the advance directive
and has placed a copy in the chart. If the patient’s wishes differ from those of his or her family or health care provider, make sure that the discrepancies are thoroughly documented in the chart.
and has placed a copy in the chart. If the patient’s wishes differ from those of his or her family or health care provider, make sure that the discrepancies are thoroughly documented in the chart.
ACCUCHARTADVANCE DIRECTIVE CHECKLIST
The Joint Commission requires that information on advance directives be charted on the admission assessment form. However, some facilities also use checklists like the one shown here.
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If a patient does not have an advance directive, the nurse should document that the patient was given written information concerning his or her rights under state law to make decisions regarding his or her health care. If the patient refuses information on an advance directive, document this refusal using the patient’s own words, in quotes, if possible. Document any conversations with the patient regarding his or her decision making. Document that proof of competence was obtained (usually the responsibility of the medical, legal, social services, or risk management department).
Nursing Documentation Regarding Patient Advanced Directive
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ADVICE TO PATIENT BY TELEPHONE
Nurses, especially those working in hospital emergency departments (EDs), frequently get requests to give advice to patients by telephone. A hospital has no legal duty to provide a telephone advice service, and the nurse has no legal duty to give advice to anyone who calls. The nurse should check the facility’s policy and procedure manual to determine whether nurses are allowed to give telephone advice.
The best response to a telephone request for medical advice is to tell the caller to come to the hospital because the nurse or other health care provider cannot assess the caller’s condition or treat him or her over the phone. One exception is a life-threatening situation, in which someone needs immediate care, treatment, or referral.
If nurses do dispense advice over the phone, they should keep in mind that a legal duty arises the minute the nurse says, “OK, let me tell you what to do.” This creates a nurse-patient relationship, and the nurse is responsible for any advice given. The nurse who starts to give advice by telephone cannot decide midway through that the situation is too difficult to handle and simply hang up; that could be considered abandonment. The nurse must give appropriate advice or a referral.
Essential Documentation
If the nurse’s facility allows telephone advice or has a triage service, there should be a system of documenting such calls—for example, by using a telephone log. The log should include:
date and time of the call
caller’s name, if he or she will give it
caller’s address
caller’s request or reason for seeking care
disposition of the call, such as giving the caller a poison-control number or suggesting that the caller come to the ED for evaluation
name of the person who made that disposition
The nurse should document the information given to the patient. (See Logging calls for telephone advice below.)
LEGAL CASEBOOKLOGGING CALLS FOR TELEPHONE ADVICE
Some nurses hesitate to use a log to record advice given by telephone because they assume that if they do not document, they will not be responsible for the advice they give. This assumption is faulty. A patient may make only one call to the hospital, usually about something important to him or her. The patient will remember that; the nurse may not.
The telephone log can provide evidence and refresh the nurse’s recollection of the event. For example, it may remind the nurse that he or she did not tell the patient to take two acetaminophen tablets to lower a fever of 105°F (40.6°C). Instead, the nurse told the caller to come to the ED. Or maybe the nurse told a young athlete to come to the ED for an x-ray of an ankle injury.
When the nurse logs such information, the law presumes that it is true because it was written in the course of ordinary business.
Nursing Documentation of Telephone Advice
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AGAINST MEDICAL ADVICE, DISCHARGE
Patients may leave a health care facility against medical advice (AMA) because they don’t understand their condition or treatment, have pressing personal problems, want to exert control over their health care, or have religious or cultural objections to their care.
Although a patient can choose to leave a health care facility AMA at any time, the law requires clear evidence that the patient is mentally competent to make that choice. In most facilities, an AMA form (also known as a responsibility release form) serves as a legal document to protect the nurse, the health care providers, and the facility if any problems arise from a patient’s unapproved discharge. (See Patient discharge against medical advice below.)
LEGAL CASEBOOKPATIENT DISCHARGE AGAINST MEDICAL ADVICE
The patient’s bill of rights and the laws and regulations based on it give competent adults the right to refuse treatment for any reason without being punished or having their liberty restricted. Some states have turned these rights into law, and the courts have cited the bills of rights in their decisions. The right to refuse treatment includes the right to leave the hospital AMA at any time, for any reason. All the nurse can do in such cases is to try to talk the patient into continuing his or her care.
If a patient still insists on leaving AMA and the facility has a policy on managing the patient who wants to leave, the nurse should follow it exactly. Adhering to policy will help to protect the hospital, coworkers, and the nurse from charges of unlawful restraint or false imprisonment.
The nurse should provide routine discharge care. Even though the patient is leaving AMA, the patient’s rights to discharge planning and care are the same as those of a patient who is signed out with medical advice. Therefore, if the patient agrees, escort him or her to the door (in a wheelchair, if necessary), provide information for support services, and offer other routine health care measures. These procedures will protect the facility as well as the patient.
Essential Documentation
The nurse should have the patient sign the AMA form, then clearly document the following:
patient’s reason for leaving AMA
that the patient knows he or she is leaving AMA
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