Proper Documentation: A Key Topic in Training Programs for Elder Abuse Workers
Journal of Elder Abuse & Neglect, Vol. 1 (3) 1989 © 1989 by the Haworth Press, Inc. All rights reserved.
Melanie Hwalek, PhD
Abstract. Over the past decade, almost all states in the U.S. have passed legislation related to elder abuse. Most of the legislation mandates that Adult Protective Services (APS) workers assess the validity of reports of alleged elder abuse or neglect. Some states also mandate these workers to plan and manage services available to victims. Assessing and serving the victims and their families requires that APS workers have knowledge and skills in many areas. One important skill is properly documenting the assessment process. In this paper, a case is made for including proper documentation as an important topic in any APS training program. Then, a systematic method is suggested for training APS workers in how to document their assessments of cases.
Common Topics for Training APS Workers
Within the last decade, almost all states in the U.S. have passed some legislation related to elder abuse and neglect (Traxler, 1986). In most states, the elder abuse laws mandate Adult Protective Services (APS) to investigate reports of abuse and neglect and to determine whether the alleged abuse is substantiated. In some states, these workers are also mandated to develop a plan of services for victims to reduce the incidence of future abuse or neglect.
Because of the demand placed on state social service departments for implementing elder abuse legislation, there has been growing interest in determining the qualifications and skills needed by case workers who have the responsibility to assess, and intervene with, victims. An effective training program should assure that all APS workers have the required qualifications and skills.
Basic information for any APS training should be an understanding of the workers’ roles within the state’s elder abuse and neglect legal and service network, the way in which the elder abuse program operates in the state, the methods by which decisions are made, and the persons or agencies by whom investigation and interventions are carried out. Knowing the paper flow of reports and forms is essential to understanding the process of assessing and assisting victims and their families.
Another basic training topic is the review of theories and research finding related to the causes, dynamics, and symptoms of elder abuse and neglect, including all types of elder abuse recognized in the state’s legislation. It is important to distinguish between causes and correlates of physical and psychological abuse, other perpetrated neglect and self-neglect, and exploitation. Detailed symptoms of each type of abuse, neglect, and exploitation should be covered, along with physical, environmental, and behavioral indicators for both the alleged victim and alleged abuser. Differentiating between signs of intentional abuse and abuse or neglect unintentionally perpetrated should also be part of the worker’s repertoire.
Types of evidence and tips on how to gather evidence are vital training topics. Workers should learn their state’s system for assessing the physical and mental competence of victims as well as the ethical dilemmas related to the victim’s right to refuse treatment.
Training must prepare the worker to handle difficult clients and to prevent and respond to dangerous situations. For these purposes, risk factors for danger, and the use of these clues to prevent danger or crises from occurring, should be added to the curriculum.
Working with people is another necessary skill. Staff should understand, for example, when and how to involve the police. In particular, APS personnel must know how to handle incompetent victims. They should be taught how to obtain evidence from incompetent elderly and how to work with confused elderly during the assessment process.
Perhaps, the most difficult and time consuming task faces by an APS worker is making the substantiation decision (cf. Hwalek and Sengstock, 1982) because often clear and decisive evidence is lacking (cf. SPEC Associates, 1987). During training, the information presented on the previous topics should be coordinated into the final phase of the assessment, which is making the substantiation decision. How to methodically review the evidence obtained during the investigation process is an essential training topic at this point. The state’s system for reviewing the case with supervisors or elder abuse team members should also be discussed at this phase of the training. In addition to state laws that are used to handle elder abuse cases, assist victims, prosecute abusers, and protect reporter and workers, any laws related to guardianship, domestic violence, living wills, power of attorney, etc., should be part of the training.
Finally, training should include the procedure used by the APS worker to determine the service needs of the elder abuse clients. The focus of the section of training should be on the empowerment of victims. Elder abuse workers must remember that victims should have the final say about any plan to resolve their abusive situations. Through effective care planning, the victims should feel that they are in control of their own lives by being given the opportunity to select or refuse alternative plans. This module of training should cover the ethical issues in providing services to elder abuse victims such as: speed of action, not blaming the victim, the victim’s right to refuse services, not making the situation worse, and the importance of giving the victim more than one choice. Principles of effective case work should be discussed, including how to decrease social isolation and increase distance between the abuser and victim. Providing a sense of reality is also an important principle in effectively planning services.
Proper Documentation: The Common Thread
A common thread in all of the aforementioned training topics is an understanding of what constitutes proper documentation of the assessment and intervention process. Case records serve as a means for communicating information among staff at the agency, as well as among different agencies involved in the case. Accurate case notes can help the worker and supervisor in understanding the dynamics of the situation, in making the substantiation decision, and in routing the case properly through the service delivery system.
Adequate documentation can help the elder abuse service network identify gaps in services and improve the quality of agency services. Gaps identified and documented in case records provide evidence that the state planning agencies can use to request additional funding from the legislature or from philanthropic organizations. Often, case examples have more impact on these decision-makers than statistical information.
Good documentation helps protect the worker and the agency in lawsuits and provides facts to the prosecuting attorney in cases of intentional abuse or neglect. Documents created during the assessment process can potentially be the most damaging evidence in court. Such documentary evidence is better than personal testimony, and expert testimony based on records is more strategic than an eye witness testimony without records. Legal attacks on documentation are weak, because one would have to prove that the documentation is false. Legal experts indicate that good records presume that good services are being provided to the client; bad records presume bad service (Marks, 1987).
In summary, proper documentation is an essential element in investigating allegations of elder abuse and neglect. Yet poor documentation is endemic to the social service system. Regardless of the types of clients served, many agency representatives have bemoaned the fact that their records are not kept in the best possible manner. And many workers are reluctant to place great emphasis on their case records, because such “paper work” takes precious time away from their other responsibilities of working directly with clients. Because of the importance placed on the agency records and because of the value of good documentation throughout the entire elder abuse system, it is essential that techniques of proper documentation be a topic in APS training programs.
Systematic Training in Proper Documentation
Why is Documentation Important?
The first step in training APS workers is convincing them of the importance of adequate documentation. APS workers are often overburdened with large caseloads and insufficient resources. Often, direct client contacts are more important to them than the state of their case records. Therefore, the first task of training is to prove to the APS workers why proper documentation is important to their clients, to themselves, to their agency, and to the state elder abuse system. Many of the arguments presented above should be discussed at the beginning of this training. A final argument to convince workers that they should emphasize their documentation skills can be provided by asking if any worker has had records subpoenaed by the courts. An explanation of this experience and possible embarrassment because of the scrutiny of their records can be potent in convincing others of the importance of keeping good documentation.
Essential to adequate documentation is having a systematic method for making observations. An adequate elder abuse assessment system should have in place standard observational categories to guide workers in gathering evidence. Observational categories should include information about the dynamics of the situation, specific indicators of abuse or neglect, whether abuse or neglect is substantiated, and service needs of the victim, abuse, and family.
Observational categories for defining the dynamics of the situation include characteristics of both the alleged victim and the alleged abuser. The first information that should be obtained includes the location of the alleged victim, the reason for the report, and the possible dangers present. Obvious identifying information is the alleged victim’s name, telephone number, address, direction to the home, if the alleged victim is in immediate danger, or needs immediate assistance, and if there is danger present in the house. Reasons why the reporter called is also important in identifying the alleged victim’s immediate situation, as well as any information that can identify the alleged abusers and type(s) of abuse or neglect suspected.
During the assessment process, further information should be obtained about the alleged victim. This includes information about marital status, whether the alleged victim is living with his/her spouse or ex-spouse, and whether the spouse is the alleged abuser. Knowing the ethnic background can be helpful in determining the cultural strengths available to the alleged victim and barriers likely to be encountered during the assessment process. Does the alleged victim understand English? Can he or she read and write English? Will an objective translator be necessary to help the worker obtain further information?
Information about the legal status of the alleged victim should be obtained, including whether there is a legal guardian or representative payee or whether someone has power of attorney over legal affairs. If any of these exist, the name and location of the person should be obtained. The social security number is another relevant piece of information. Does the alleged victim have a social security number? If not, why not? Is the alleged victim willing to provide the number to the worker?
Financial information about the alleged victim must also be documented. What is the total amount of money received on a monthly basis by the alleged victim? What does the alleged victim really have access to? Are the necessary living expenses being met? How?
The worker should learn about the living arrangements of the alleged victim. With whom does the victim live? Does the alleged victim own his or her home? How any people are living there? How are they related? Who maintains the home? Is the alleged abuser living with the alleged victim? Can he or she get around the house independently? Can he or she take care of major activities of daily living, such as getting dressed, cooking, cleaning, shopping, banking, and paying bills? Is the alleged victim bed-bound? Disorientated? Confused? If signs of mental incompetence are present, a standard mental status questionnaire should be available to the worker to determine if further psychological and/or psychiatric assessments are indicated.
Finally, the family dynamics should be described. From the worker’s perspective, what is the family situation? Are there struggles over power, control, or money? Who controls whom? What is the level of risk or imminent danger to the alleged victim? Is there potential family support that can be accessed to alleviate the problem? Are there alliances among family members? Are there neutral parties? Is there past history of substance abuse or violence among any family members? Are some family members caregivers to the alleged victim? Are there non-family caregivers in the home? Is there denial of the needs of the alleged victim? Is there denial of the abuse or neglect? Is this a case of self-neglect?
Most of the same information that is obtained about the alleged victim should also be obtained about the alleged abuser(s), especially if he, she or they are living with the victim or are members of the family. In addition, it is important to document whether the alleged abuser(s) is aware that a report was made and, if so, how this information was handled. It is also important to document whether the alleged abuser(s) plays a key role in caregiving. Finally, the worker should document evidence suggesting whether the abuse or neglect is intentional. Behavior patterns of the abuse likely to suggest intentional abuse include denying the elder’s situation, refusing needed services, being uncooperative with the worker, not letting the worker see or be alone with the alleged victim, not letting a competent elder answer the worker’s questions, and giving an explanation that is inconsistent with an observable injury or condition of the alleged victim.
In addition to the documenting the dynamics of the situation, specific indicators of abuse or neglect that are uncovered during the assessment process should be part of the case records. It is advisable to have a list of the specific symptoms of each type of abuse or neglect listed in the state’s legislation. There are a number of existing generic instruments that can be used during training to help teach the symptoms of elder abuse (cf. Sengstock & Hwalek, 1986; Ferguson, 1983; Quinn & Tomita, 1986). These can be effective teaching instruments when integrated with the specific definitions used by a particular state.
Once the evidence is gathered and properly documented, the case record should also include the specific conclusion of the worker about whether abuse or neglect is substantiated. Documentation should not only indicate the decision but also how the decision was made. Was the decision made by one worker, by the worker with the supervisor, or by a team? Who else was involved in the decision-making process? What specific evidence or information was key in convincing the decision-makers to substantiate or not to substantiate the allegations?
Documentation of the aforementioned information should assist the worker in determining the service needs of the victim, abuser(s), and family. Again, a comprehensive list of services should be available to help the worker review possible treatment strategies. The names and telephone numbers of agencies providing these services in the applicable geographic area and any eligibility requirements should also be provided for care planning. Also, service needs that cannot be met by the present service system and any services that were offered but refused by the victim or the caregiver must be documented. Finally, it is very important to document that the victim was offered more than one treatment plan and that the major decision about services was truly made by the victim or the legal spokesperson for the victim.
Sources of Evidence
In properly documenting the assessment process, the worker should be given training about the different sources from which evidence about the case can be obtained. The alleged victim, alleged abuser, and family member are only a few of many sources from whom to seek evidence. In the investigation process, the worker should consider obtaining information from other sources as well.
Collateral contacts such as neighbors, friends, coworkers, supervisors, and other agencies that may be providing services are valuable sources of information. These individuals can help the worker determine consequences of inadequate intervention and possible dangers involved in the situation.
Records or other reports about the alleged victim or abuser can be important to the assessment process. These include records from other medical facilities, banks, police, other social agencies, and death records. Other data bases can also assist in the assessment process, such as the telephone directory and other resource directories for locating names and phone numbers of neighbors or agencies likely to know the alleged victim or abuser. The Bresser’s Index, for example is a very useful data base which is available at most public libraries. It contains lists matching addresses with listed phone numbers and can be used to locate neighbors of alleged victims or anonymous reporters.
Professionals and paraprofessionals can also provide key information to the worker. Talking to the alleged victim’s or abuser’s physician, visiting nurse, chore-homemaker, attorneys, police, social workers, dentists, etc., can provide clues about the dynamics of the situation not likely to be revealed directly by family members. Information obtained from these sources must be documented in the case records; and, when the evidence is recorded, the source of the evidence must also be recorded.
Writing the Entry
Having a systematic method for observing evidence and making an assessment is only one part of good documentation. The second key element is how the obtained information is written in the case file. Case note entries should be concise, factual and objective. In addition, there are two types of criteria to consider when writing an entry into the case notes: evidentiary considerations and treatment considerations.
Evidentiary considerations are criteria that will ensure that written records are admissible in court and that the recorded information will be difficult for a defense attorney to refute. Evidentiary criteria that defense attorneys are like to look for are:
- Omissions. The written records should not leave any questions about what was seen or done. For example, stating only that the “public health nurse was called to visit the alleged victim” leaves many question about the reason for the call, time of call, results of the call, etc.
- Contradictions and inconsistencies. There should be no entries that suggest the worker contradicted him/herself and that inconsistent treatment was applied. For example, if it is documented that an alleged victim is in need of physical assistance with dressing, it should not be stated in the case notes that the victim dresses him/herself.
- Time delays and unexplained time gaps. If a case is being assessed and the substantiation decision has not yet been documented, there should not be a long time period between entries in the case notes. This suggests that nothing was down about the case for a long period of time. If there is information about the case that was not entered chronologically, the case records should record the date and time of the late entry and the date and time it should have been entered. Reasons for late entries should also be recorded.
- Alterations or appearance of alterations. All information written in the document should be clearly visible. “White-out” should never be used nor should erasures be apparent. Wide open spaces in a record or blackened areas can be interpreted as trying to hide information. Corrections should be made with a single thin line, initialed and dated, with an explanation in the margin stating why the information has been deleted and if/where it has been replaced. Missing pages in a chronological log are also indicative of alterations.
- Lack of supervision by staff. The written documents should not show evidence of missing staff supervision. Meetings with supervisors about the case should be documented in the case record.
- Illegibility. A favorite way for attorneys to discount expert testimony is to ask an expert to try to read an illegible entry he/she made in the case records.
- Extraneous remarks of frivolity, unprofessionalism, confusion, or inattention. The case records should never be used to make jokes or to vent frustrations. They should always be objective and have the best interest of the worker and agency in mind.
- Disagreements or complaints of staff. Case records should never record disagreements on how to handle the case or the worker’s frustrations with the administration or agency policy.
- Opinions instead of behavioral records. Recorded information should be descriptive and not interpretative. If an opinion is relevant, such as the substantiation which reflects a conclusion, behavioral evidence should explain the opinion. Behaviors are measurable, opinions are not. Words such as screaming, biting, and crying are behavioral. Words such as frustrated, angry, and dangerous are not behavioral.
- Unsigned entries. Every entry made in case notes should easily identify the person who made the entry.
- Cryptic/unexplained remarks. The case record should contain only information relevant to the particular case and the information should be related to the purpose of the documentation, which is to assess the validity of the allegation of abuse and neglect and to determine service needs.
- Incomplete remarks. Finally, written entries should be complete. It is insufficient to record that “I visited Mrs. Jones today, all is well.” What was done on the visit? What was said? What behaviors or other evidence justify the opinion that all is “well”?
Treatment considerations are those criteria that establish that the assessment was properly conducted. Case records should never indicate”
- Negligence. Case notes should not suggest that staff neglected the client, such as not following up in emergency situations or failing to provide adequate care.
- Malpractice. Case notes should not suggest any types of malpractice such as “waiting for the abuser to make a mistake.”
- Failure to appropriately treat. Case notes should document any treatments that were provided to the alleged victim. Documenting injuries without documenting what the worker did about the injuries could be used to indicate that the agency failed to properly treat the victim. Remember that, as far as the courts are concerned, if treatment was not recorded, it is assumed that it did not occur (Marks, 1987).
- Anger or animosity. Anger and animosity are common feeling a worker my experience dealing with intentionally perpetrated abuse or neglect. However, the expression of these feelings should not be in writing in the case notes.
- Entries that contradict decisions. Decisions made about the case should reflect the facts presented in the case record. Services offered to the victim should correspond with documented needs.
- No connection between written documentation and treatment. Treatment that is provided should be backed by evidence gathered and documented about the case. For example, if substance abuse treatment is provided to the victim, there should be evidence in the case records of a history of substance abuse or behavioral/situational evidence that indicates the need for this type of treatment.
- No indication of follow-up. If follow-up is a service to be provided to the victim, any follow-up activities should be recorded along with what was observed and what was done about the current state of the victim.
Confidentiality: The Last Consideration
A final topic in training about proper documentation is the workers’ obligations to confidentiality. Each professional discipline involved in elder abuse assessment and intervention has a code of ethics concerning confidentiality of client files. Local and state agencies involved with elder abuse should also have written policies and procedures both for gathering evidence and for maintaining the confidentiality of case records. Training should clarify who has access to client records, how the agency protects client confidentiality, and what to do if case records are lost or stolen.
Summary and Conclusions
In summary, case workers investigating elder abuse and neglect must have considerable knowledge and skills in many areas. Knowing how to properly document the assessment process is an important thread integrating the worker’s skills in assessment, dealing with difficult clients, handling dangerous situation, making the substantiation decisions, and managing treatment to victims, abusers, and their families. Therefore, it is recommended that any training program for APS workers include a module in proper documentation.
According to David Marks (1987), an agency’s records memorialize the assessment of abuse and neglect, as well as the client’s history, services, and progress in the program. Documents kept on an elder abuse client should serve to clarify the problems surrounding abuse or neglect as well as clarifying remedial actions.
This article began with basic information for training APS workers and then suggested the types of topics that should be covered in a module on documentation. It pointed out ways to observe evidence in the assessment process, sources of evidence, and the proper methods or writing entries into case notes. The goals of this training module are to motivate workers and to provide a proactive system for substantiating the efforts needed to assess elder abuse cases, for documenting the need to meet gaps in services, and for protecting both the worker and the agency if the agency’s records are subpoenaed by the courts.
Ferguson, D., & Beck, C. (1983). H.A.L.F. – A tool to assess elder abuse within the family. Geriatric Nursing, September/October, 301-304.
Hwalek, M.A., & Sengstock, M.C. (1982). Developing an index of elder abuse. Final report to the Department of Health and Human Services. Administration on Aging, Grant Number 90-AR00040.02
Marks, D. (1987). Lecture at Elder Abuse Conference in Lansing, Michigan. Sponsored by St. Vincent Hospital, Toledo, Ohio.
Quinn, M., & Tomita, s. (1986). Elder abuse and neglect: Causes, diagnosis and interventional strategies. New York: Springer.
Sengstock, M.C., & Hwalek, M.A. (1986). Sengstock-Hwalek comprehensive…
Melanie Hwalek is President of SPEC Associates, a research and training firm. She has a PhD in Social Psychology and is Adjust Assistance Professor of Psychology at Wayne State University. She is co-developer of “Identify the Victim”, an audio-slide presentation, and of the Sengstock-Hwalek Comprehensive Index of Elder Abuse. The author would like to acknowledge the Illinois Department of Aging for partial support in the preparation of ideas related to this article and to thank the APS workers throughout the U.S. who contributed many of the thoughts discussed herein.