Clinician’s Role in the Documentation of Elder Mistreatment

Elizabeth Pham, MD, Resident Physician, Department of Medicine, University of California, Irvine Medical Center, Orange, CA, USA.
Solomon Liao, MD, Associate Clinical Professor, Department of Medicine, University of California, Irvine Medical Center, Orange, CA, USA.

As the population ages, elder mistreatment is a growing concern in North America, and it includes physical and financial abuse and neglect. Careful documentation of the history, physical examination, and diagnostic data help achieve a clinical assessment that may be crucial to the outcome of a legal case and the protection of a patient. Good medical documentation ultimately saves clinicians time and demonstrates competency. This article discusses the items clinicians need to document in suspected cases of elder mistreatment. The emphasis is on issues that are above or beyond those performed in a routine clinical encounter.
Key words: elder mistreatment, elder neglect, elder abuse, financial exploitation, forensic documentation.