AS A NURSE, you may be the first professional caregiver to recognize and report incidents of suspected abuse. Besides physical violence, abuse includes neglect and sexual, emotional, and psychological abuse. Abuse victims can be of any age and either gender. If you observe any signs of abuse while caring for a patient, you must document your findings and pass the information along to the appropriate authorities.
In most states, you're required by law to report signs of abuse in children, older adults, and the disabled, and failing to report suspicions may be considered a crime. Most reporting laws are written to protect vulnerable populations. If you believe a crime against an adult or a child is being committed, you must report the facts to your supervisor and other agencies according to your facility's policy.
Certain cultural practices that produce bruises or burns, such as coin rubbing in Vietnamese groups, may be mistaken for child abuse, but you're not expected to make this judgment. The federal Child Abuse Prevention and Treatment Act, which applies in all states, protects you from liability if your suspicions prove unfounded, provided you filed the report in good faith.
Follow facility policy and procedure if you suspect abuse. The suspected victim should be interviewed apart from the suspected abuser, if possible. Note inconsistencies in their stories. Document your physical assessment findings in detail, using illustrations and photographs as necessary, per your facility's policy.
When documenting suspected abuse, record only the facts and leave out personal opinions and judgments. Note inconsistencies in histories, evasive answers, delays in treatment, medical attention sought at other facilities, and the person caring for the individual during the incident. Describe the patient's response to treatments given. Direct quotes provide good evidence of why you think abuse has occurred.
Record the names and departments of people notified within the facility. Also provide the names of people notified outside the facility, such as the police department and welfare agencies. Record any visits by these agencies. Include any teaching or support given. Follow up on the report to make sure the facility or agencies notified report your concerns to the proper authorities.
Chart Smart: The A-to-Z Guide to Better Nursing Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:1-3.
Complete Guide to Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008: 357-358.