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, a nurse is required by law to report signs of abuse in children, older adults, and the disabled. (See Common signs of neglect and abuse, page 2.) Use appropriate channels for your facility and report your suspicions to the appropriate administrator and agency. Document suspicions on the appropriate form for your facility or in your 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 Tour role in reporting abuse, page 3.)

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, you review and sign them. These forms tell the health care team members about the patient’s abilities, degree of independence, and special needs so they can determine the type of assistance each patient requires. Tools that are useful in assessing and documenting ADLs include the Katz index, Lawton Instrumental Activities of Daily Living scale, and Barthel index and scale.

An advance directive is a legal document used as a guideline for medical care of a patient with an advanced disease or disability who is no longer able to indicate his own wishes. Advance directives also include living wills (which instruct the doctor regarding life-sustaining treatment) and durable powers of attorney for health care (which names another person to act on the patient’s behalf for medical decisions in the event that the patient can’t act for himself).

Because laws vary from state to state, be sure to find out how your state’s laws apply to your practice and to the medical record.

If a patient has previously executed an advance directive, request a copy for the chart and make sure the doctor is aware of it. Many health care facilities routinely make this request a part of admission procedures. (See Advance directive checklist, page 10.)

In most states, the advance directive is a legal document formulated by the patient while he’s of sound mind that dictates the patient’s wishes should he become incapacitated and unable to make decisions. Ideally, the patient should discuss his feelings and desires with his family members, and they should agree to the patient’s desires. However, there may be occasions when the family doesn’t agree with the advance directive or want it activated. Should this occur, the legality of the situation dictates that the living will is upheld. The family’s rights are superseded by the living will.

Should the family members express opposition to the advance directive, notify the patient’s attending physician, the nursing supervisor, and the risk manager. The family members can be encouraged to discuss their feelings with the patient and these individuals, or they may be referred for counseling that may help them in their situation.

Some patients wait until they’re hospitalized to consider an advance directive or to make significant legal decisions. If a patient wishes to execute a living will during his hospital stay, you aren’t required, or even permitted in some states, to sign as a witness. Check with your state’s laws about whether you can sign as a witness. In many facilities, the social services or risk management department oversees this process. Find out which is the responsible department in your facility. The person who acts as witness can be held accountable for the patient’s competence. Keep in mind that only a competent adult can execute a legally binding document. To prevent a patient’s relatives from later raising questions about his competence, the record should include documented proof of competence (usually the responsibility of the medical, legal, social services, or risk management department).