Table 4 lists the essential features of a history for identifying a mistreated elder patient. The physical examination is often used as legal evidence of mistreatment. Table 5 lists the basic features of a physical examination in assessing a mistreated elder patient. 8 Laboratory and imaging studies should be performed to confirm any suspicious findings in the history and physical examination. The presence of dehydration and malnutrition can be established with simple laboratory tests such as a complete blood count and measurement of blood urea nitrogen, creatinine, total protein and albumin levels.
Radiographic studies provide evidence of old and new fractures.
Unfortunately, proving that a fracture was caused by abuse can be difficult. Documentation Documentation of all findings may be entered as evidence in criminal trials or in guardianship hearings. Documentation must be complete, thorough and legible. This need mandates a careful collection of physical evidence, which is critical in cases of suspected sexual or physical abuse. Laboratory data and, when possible, photographs should be used for verification of written documentation.