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Proper Documentation: A Key Topic in Training Programs for Elder Abuse Workers

NCJ Number
125383
Journal
Journal of Elder Abuse and Neglect Volume: 1 Issue: 3 Dated: (1989) Pages: 17-30
Author(s)
M Hwalek
Date Published
1990
Length
14 pages
Annotation
Adult Protective Services (APS) workers must be trained to understand their roles in the elder abuse and neglect legal and service network, to understand theories and research related to the causes and symptoms of elder abuse, to handle difficult clients, to work effectively with people, to make substantiation decisions, and to determine the service needs of elder abuse clients. Proper documentation of the assessment and intervention process is necessary to identify gaps in service and improve its quality and to protect the worker and agency in case of lawsuits.
Abstract
A systematic method of observation is essential to adequate documentation of the dynamics of the situation, specific indicators of abuse or neglect, substantiation of abuse or neglect, and service needs of the victim and abuser. During the assessment process, further information about the victim's personal and legal status, financial and living arrangements, functional barriers, and family dynamics should be obtained. Necessary information about the abuser includes whether he or she lives with the victim, is aware of the report of abuse, is financially dependent on the victim, and acts as a primary caregiver of the victim. Information can be gathered from primary sources (victim, abuser, family members), collateral contacts (friends, neighbors, coworkers), other records about the victim or abuser, and professionals or paraprofessionals involved with the victim and abuser. When writing the entry, case notes should be concise, factual, and objective. Evidentiary and treatment considerations are essential to writing case notes. Finally, all case notes and records must be treated with confidentiality. 7 references. (Author abstract modified)