Mandated reporting decision record
Record the reasoning and the action when suspected abuse or neglect arises.
How this document is used well
The threshold for reporting is almost never certainty. In most jurisdictions the standard is reasonable suspicion or reasonable cause to believe — a much lower bar than proof, and one deliberately set so that clinicians do not investigate. Investigation is the agency’s job. Yours is to notice, to report within the statutory window, and to keep working with the patient afterwards.
Telling the patient
Where it is safe to do so, tell the patient you are reporting, before you report, and explain why. This is consistent with the informed consent you gave, and it is very often the difference between a report that ends the treatment and one that does not. Where telling would increase danger to a victim, do not.
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7 required fields outstanding: What was disclosed or observed, in the person’s words where possible; Category; Jurisdiction and statute …