Name of the Procedure:

Elder Maltreatment Screen Documented as Positive, Follow-up Plan Not Documented

Summary

An elder maltreatment screening aims to identify older adults experiencing abuse, neglect, or exploitation. This specific documentation (G8735) denotes that the screening was positive for maltreatment, but no follow-up plan was recorded, and no reason for this lack of documentation was provided.

Purpose

The procedure aims to detect signs of physical, emotional, or financial abuse in elderly patients. The goal is to ensure the safety and well-being of older adults by identifying maltreatment early and addressing it promptly.

Indications

• Unexplained injuries or frequent hospital visits.
• Signs of neglect such as poor hygiene or malnutrition.
• Emotional distress or withdrawal.
• Financial irregularities or exploitation.

Preparation

• No special preparations are typically required.
• Standard medical history review and physical examination may be performed.

Procedure Description

1. A clinician asks the elder patient a series of standardized questions.
2. Observations of the patient's physical and emotional state are made.
3. The clinician documents the responses and observations.
4. Positive findings (indicating possible maltreatment) are recorded.
5. A follow-up plan should be documented to address the positive findings, although in this case, it was not documented, and no reason was provided.

Tools, Equipment, or Technology Used:

• Standardized screening tools or questionnaires.
• Patient medical records.

Anesthesia or Sedation Details:

• Not applicable.

Duration

The screening typically takes 10-20 minutes.

Setting

The procedure can be performed in various settings, including hospitals, outpatient clinics, and primary care offices.

Personnel

• Primary care physician or clinician.
• Nurse or medical assistant for documentation.

Risks and Complications

• Minimal risks are associated with the screening itself.
• Potential emotional distress for the patient when discussing sensitive issues.

Benefits

• Early detection of abuse or neglect.
• Improved safety and quality of life for the elder.
• Timely interventions to prevent further maltreatment.

Recovery

• Immediate recovery post-screening as it is non-invasive.
• Ongoing monitoring and follow-up appointments may be necessary to address the identified issues.

Alternatives

• Home visits by social workers to assess the living conditions.
• Consultation with elder care specialists.
• Involvement of family members or caregivers to provide a broader context.

Pros and Cons of Alternatives:

• Home visits may provide more comprehensive information but can be more intrusive.
• Specialist consultations can offer more targeted interventions but may require additional appointments and resources.

Patient Experience

• The patient may feel uneasy discussing personal matters but should be reassured that their safety and well-being are the priority.
• Comfort measures include a supportive environment and empathetic communication.
• Pain management is not typically required, but emotional support should be available.