By Alexis Coulourides Kogan, PhD, MSG
June 28, 2019
Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra
Health care providers in all settings evaluate older adults with evidence of physical injury. For approximately 10% of these patients, the injury may be linked to some form of elder abuse or neglect. However, it is often not always apparent during the initial medical encounter that the injury could be connected to abuse. In fact, it may be weeks, months or even years later that abuse is suspected. When physical injuries are not considered suspicious, they are usually not documented in any detail, if at all, in the medical chart. This creates an important challenge once abuse is actually suspected because incomplete and inadequate documentation of injuries from prior medical visits means an absence of a “paper trail” of quality documentation. This can significantly impact whether justice and protection can be achieved for a victimized older adult.
In the absence of any standardized tools to support physician documentation of physical injuries in older adult patients, a research team from the Keck School of Medicine of USC’s Department of Family Medicine and Weill Cornell’s Department of Emergency Medicine sought to do exactly that. They aimed to use insights from experts to develop a universal tool to assist clinicians in appropriately and completely documenting physical findings in injured older adults for potential future forensic investigation of abuse or neglect.
The team used previous research and existing tools for child abuse and intimate partner violence to inform the development of the geriatric documentation tool before eliciting and incorporating feedback from interviews with 11 elder abuse experts in the fields of criminal justice (detectives and prosecutors) and medicine (forensic pathologist, geriatricians, and emergency medicine physicians). All experts agreed that medical providers’ documentation of geriatric injuries is usually inadequate for purposes of investigating alleged elder abuse/neglect. They highlighted several elements needed for forensic investigation: initial appearance before treatment is initiated, complete head-to-toe evaluation, documentation of all injuries (even minor ones), and documentation of pertinent negatives. Several experts also noted the value of photographs to supplement written documentation. Informants identified practical challenges to utilizing a tool for providers, including the burden of additional or parallel documentation in a busy clinical setting and how to integrate it into existing electronic medical records.
This feedback was incorporated into a second draft of the geriatric injury documentation tool and was used in two focus groups among physicians at an emergency department in New York City and family medicine department in Los Angeles. The purpose of the focus groups was to assess the feasibility of incorporating the tool into clinical practice. Participants’ comments focused on: minor edits to the tool, perceived utility of the tool (helpfulness of the body diagrams and pertinent injury characteristics), incorporating the tool into the electronic health record (EHR), and time constraints. Feedback informed the final version: Geriatric Injury Documentation Tool (Geri-IDT). This tool is intended to be used during medical encounters for all older adult patients that present with physical injury(ies) whether or not elder abuse is actually suspected. Using child abuse and intimate partner violence as a paradigm, creating and implementing a tool to document physical findings in older adult patients has the potential to improve clinical documentation and medical care for this patient population. Additionally, utilizing a simple tool for documentation will be helpful in any circumstance, whether related to abuse or not. Good documentation is as important for avoiding unwarranted accusations as it is for identification of suspected abuse. In a field that has been plagued by poor and inadequate documentation, any additional burden and time commitment associated with incorporating the Geri-ITD into medical encounters with older adult patients may be outweighed by the potential value it brings. However, future research is need to test the Geri-IDT’s acceptance, impact, and ability to be incorporated into electronic health records.