Name of the Procedure:

Elder Maltreatment Screen Not Documented; Documentation that Patient is Not Eligible for the Elder Maltreatment Screen at the Time of the Encounter

Summary

This procedure involves recording that a patient is not eligible for an elder maltreatment screening during a medical visit. It ensures that there is documentation for the lack of performing this specific screening.

Purpose

The purpose is to ensure that there is clear medical documentation for why an elder maltreatment screen was not conducted during a patient’s encounter. This can be important for medical records, legal reasons, and ensuring appropriate care pathways are followed.

Indications

• A patient may be too ill or otherwise incapacitated to participate in an elder maltreatment screening.
• Situations where a patient is not considered at risk for elder maltreatment.
• Emergency situations where immediate care takes precedence over screening.

Preparation

There are no specific preparations required for this documentation procedure. Clinical judgment will determine the ineligibility for the elder maltreatment screening.

Procedure Description

1. The healthcare provider will assess the patient and determine that they are ineligible for the elder maltreatment screen.
2. The provider will document the ineligibility in the patient’s medical record, noting the specific reasons why the screen was not performed.
3. This documentation should follow the guidelines and standards set by the healthcare facility.
   • Tools: Electronic Health Record (EHR) system or paper medical records
   • No anesthesia or sedation is required for this documentation process.

Duration

The documentation process takes approximately 1-5 minutes.

Setting

This documentation can be performed in any healthcare setting, such as a hospital, outpatient clinic, or a primary care office.

Personnel

• The healthcare provider, such as a physician, nurse practitioner, or physician assistant, is responsible for the assessment and documentation.

Risks and Complications

There are no direct risks or complications related to this documentation procedure. However, failure to document accurately may have legal or medical repercussions.

Benefits

• Ensures clarity in medical records.
• Provides legal protection through proper documentation.
• Enhances patient safety by maintaining accurate documentation of care decisions.

Recovery

There is no recovery period as this is a documentation procedure. No specific post-procedure care is required.

Alternatives

• Other alternative documentation procedures may include noting patient refusal or other specific assessments recorded in their place.
• Comparing the pros and cons of not documenting versus documenting: Not documenting can result in legal risks and gaps in patient care records, while documenting provides a clear medical trail for future reference.

Patient Experience

The patient may not directly experience this procedure since it primarily involves the healthcare provider’s documentation tasks. There will be no pain or discomfort related to this procedure.