Question 10

September 9, 2015

Question:

Which of the following should be undertaken when documenting the patient's history and injuries? [Select two that apply]

Answers

Answer:

A. Make sure you include the words “patient claims” or “patient alleges” when recording the history, in order to protect yourself in case the medical record (or you) is ever subpoenaed in a judicial proceeding.

Correct Answer?

Explanation:

A. Incorrect Using words like "claims" or "alleges" can be interpreted as judgmental - as if the health care provider doesn't really believe what the patient is saying. The recommended way to document oral statements provided in the context of the patient history is to use the word "states" and to employ quotes when possible. For example, in this case, a recommended way to document the patient's account might be to write, "Patient states, 'My husband pushed me against the wall.'"

Answers

Answer:

B. Document visible injuries by use of photography whenever possible.

Correct Answer?

Explanation:

B. CORRECT Photographic documentation can be affirming to the patient, as it provides a visible record of injuries. Photographs can also be useful to the patient in the event of legal proceedings. Photographs can be made using a film or digital camera. The health care provider should obtain the patient's written consent to photography whenever possible, and should also include a signed statement next to each photograph (or accompanying the set of images) stating that the photograph was (or photographs were) taken by [health care provider name] on [date, time] and represent accurate, unaltered images of injuries observed on [patient name].

Answers

Answer:

C. Include a hand drawn or stick figure to indicate areas of pain or discomfort that are not observable by photography.

Correct Answer?

Explanation:

C. CORRECT It is not uncommon for a patient to report pain or for the health care provider to elicit tenderness in a specific area, even though there is no visible injury. In this case, a simple line drawing indicating areas of pain or tenderness can supplement written accounts of patient statements and photographs.

Answers

Answer:

D. Do not document anything in the chart. You can provide the same quality care and referrals regardless of whether you document your findings, without risking being called into court and without risking that the patient’s medical record can be accessed by the perpetrator.

Correct Answer?

Explanation:

D. Incorrect Accurate, unbiased documentation of history, physical findings, and images is key to optimal medical care for survivors of intimate partner and sexual violence.

Format:

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