BRUISE / INJURY OF UNKNOWN ORIGIN DOCUMENTATION 29
PS61
INJURY OF UNKNOWN SOURCE REPORT
(ICF only)
An injury of a more serious nature should be reported as an “injury of unknown source” when:
1. The source of the injury was not witnessed by any person and the source of the injury could not be explained by the client; and
2. The injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.
A report of this nature would also necessitate a report to the common entry point as indicated in the Vulnerable Adult Reporting Policies and Procedures. The staff person making the observation shall immediately call the Program Director and the Executive Director (218-409-8180).
|Name | |Date | |
|Date and Time Injury First Observed | |
|Size of Injury | |Location of Injury | |
Other information about the Injury:
Documentation Directions
Mark the approximate location of the injury on the body diagram below.
[pic] [pic]
Description of the injury:
Additional information / Explanation about injury:
|Staff signature/title: | |Date: | |
|PD notified |Date: | |Time: | |
|Exec. Dir. Notified (218-461-2824) | | | | |
|Office hours- (218) 722-8180, ext. 100 |Date: | |Time: | |
|Minnesota Adult Abuse Reporting Center | | | | | |
|(MAARC) notified (by whom?) | |Date: | |Time: | |
|SD notified (by whom?) | |Date: | |Time: | |
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