Documenting An Investigation
Designated Agencies are expected to document their investigation and securely store any evidence that they may have obtained in the course of the investigation. Please see your organization’s/program’s documentation and practice standards.
Please download and/or print this DR Documentation Reference Sheet. It will be a helpful tool as you go through the course.
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State the “facts”, identify if the facts have not been substantiated
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Include only what is relevant to the care of the adult
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Identifying information of the Reporter must not be disclosed
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Reporter may remain anonymous
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First-hand charting is required (i.e. nurse who witnesses an incident of abuse or neglect)
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Follow site/program specific practice and professional standards
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When in doubt, consult with your practice leader about what may or may not be documented in the medical record
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Remember Freedom of Information Legislation – the adult’s legal representative, representative and Power of Attorney may request access to records
For direction on how to document in the client medical record please refer to VCH Policies and Procedures available in the Shared Health Organizations Portal (SHOP). In addition, your program, facility, or discipline may have some practice standards and guidelines about documenting on a health record. Always ensure you follow your local practice standards and talk to your practice leader if you are not sure about documenting details of the adult protection investigation in the medical record (for example it may be 3rd party information or information specific to the reporter or the person of concern). All clinical information about an adult must be charted…More
Always ensure you follow your local practice standards and talk to your practice leader if you are not sure about documenting details of the adult protection investigation in the medical record (for example it may be 3rd party information or information specific to the reporter or the person of concern). All clinical information about an adult must be charted…More
Documenting AGA Investigations at Fraser Health
To begin all Designated Responders working at Fraser Health must follow the Documentation Policy which is available to review by copying and pasting the following URL into the search function of the FH Pulse. Please note this is not a clickable link.
http://fhpulse/clinical_resources/clinical_policy_office/Documents/0419/Policy.pdf
Further to the Documentation Policy all reports of abuse, neglect, and self-neglect of vulnerable adults received under the Adult Guardianship Act must be documented using AGA specific forms and templates which are available in Meditech (ITS) and PARIS. Designated Responders who use Meditech (PCS) must use the AGA Investigation notes which are available.
Please copy and paste the URL address below into the search function on the FH Pulse to learn about AGA documentation standards and processes. Please note this is not a clickable link:
http://fhpulse/quality_and_patient_safety/adult_abuse_neglect/Documents/Adult%20Abuse%20Documentation%20Guideline.pdf
In Interior Health, Designated Responders are required to start documenting an Adult Guardianship Investigation as soon as they receive a report or identify potential concerns of abuse, neglect or self-neglect.
Designated Responders are required to document in the medical record. Use of the Adult Guardianship Investigation/Outcome Report and the Adult Guardianship Progress Note must be used to ensure information is kept confidential in accordance with Section 46 of the Adult Guardianship Act.
In addition to medical record documentation, Designated Responders are also required to update the PSLS Re:act Reporting System so that data related to vulnerable and incapable adult can be collected and reported. (Additional resources regarding the PSLS Re:act Reporting System are under development). The PSLS Re:act Reporting System must be updated a minimum of three times during an investigation. Once during the initial report, twice during the initial interview of the vulnerable adult, and finally when outcomes have been determined and the investigation will be closed.
Please refer to theDesignated Responder Documentation Reference Sheet
