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Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter

HCPCS code

Elder Maltreatment Screen Documented as Positive, Follow-Up Plan Not Documented, Documentation the Patient is Not Eligible for Follow-Up Plan at the Time of the Encounter (G8941)

Name of the Procedure:

Common Names: Elder Abuse Screen
Technical/Medical Terms: Elder Maltreatment Screen Documented as Positive, Follow-Up Plan Not Documented, Documentation the Patient is Not Eligible for Follow-Up Plan at the Time of the Encounter

Summary

This screening procedure identifies elderly individuals who may be suffering from abuse or maltreatment. When a positive maltreatment is detected, a follow-up plan is often required but in some cases, it is documented that the patient is not eligible for such follow-up at the time of the encounter.

Purpose

Medical Conditions: Elder abuse or maltreatment
Goals: To identify cases of elder maltreatment and ensure appropriate follow-up care, or to document cases where a follow-up is not feasible at the encounter moment.

Indications

Symptoms/Conditions: Signs of physical, emotional, or financial abuse in older adults
Patient Criteria: Elderly patients showing potential signs of abuse; patients whom a routine elder maltreatment screen is standard.

Preparation

Pre-Procedure Instructions: No special preparation required for the screening itself. If follow-up examination procedures are needed, instructions will vary.
Diagnostic Tests: Preliminary assessment through patient interview and physical examination.

Procedure Description

  1. Screening Process: The healthcare provider conducts a thorough interview and physical examination to identify signs of abuse.
  2. Documentation: If maltreatment is detected, it is documented.
  3. Determination of Eligibility: If a follow-up plan is deemed essential but not feasible, the reasons for ineligibility are documented at the time of the encounter.

Duration

Typical Time: The screening can take approximately 15-45 minutes, depending on the thoroughness required.

Setting

Location: Generally performed in hospitals, outpatient clinics, or elder care facilities.

Personnel

Healthcare Professionals: Physicians, nurses, social workers, and elder care specialists.

Risks and Complications

Common Risks: Minimal physical risk from the screening process.
Complications: Emotional distress if abuse is confirmed; managing this requires immediate counseling or support measures.

Benefits

Expected Benefits: Early identification of elder abuse, appropriate documentation, and potential planning for future intervention when feasible.
Realization Period: Immediate emotional relief through acknowledgment, with long-term benefits involving appropriate social/medical intervention.

Recovery

Post-Procedure Care and Instructions: Immediate counseling or social work referral if needed.
Recovery Time: Psychological healing varies; ongoing support may be necessary.

Alternatives

Other Options: Routine physical exams, family interviews, community outreach programs on elder care
Pros and Cons:

  • Physical exams may not always reveal abuse.
  • Family interviews can be biased or unreliable.
  • Community outreach is beneficial for overall prevention but may miss individual cases.

Patient Experience

During Procedure: Patients may feel anxious or distressed as they share their experiences or undergo physical examination.
After Procedure: Potential feelings of vulnerability. Support services like counseling or case management are crucial for emotional well-being. Pain management is generally not applicable, but emotional support is critical.

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