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All emergency procedures will be recorded in the patients chart including: symptoms, time of onset of symptoms, support services, drugs administered (time and dosage), referrals or calls for support services, progression of patient’s signs and symptoms and instructions given to the patient.

B.24 REPORTING DOMESTIC VIOLENCE and NEGLECT

PURPOSE


This policy is to ensure that appropriate medical care and emotional support be given to those experiencing abuse and mistreatment from others and to report this suspicion to the proper authorities. This policy is designed to protect those from civil and criminal liability if the report is made in good faith. (Check State laws to ensure protection from liability)
PROCEDURE

Willful physical abuse by adults is a significant cause of disability or death in young children. Reporting of suspected cases is mandatory. "In an attempt to protect children, the law requires care providers to report their suspicions to the police department or any special children's protective service operating in the community so that cases can be investigated and appropriate measures taken for the safety of the child. State law protects physicians and dentists against liability for reporting. Once suspicion of willful injury has been aroused or confirmed, protective hospitalization is mandatory to prevent possible repetition."[modify as needed to meet state requirements]

The physician or dental provider will notify the [appropriate referral agency], Tribal Police Department and the Social Services Department of their suspicions.

Circumstances Requiring Investigation


  • Frequent visits to the Emergency Department with un explained injuries

  • Evasion, contraindications and conflicting statements about circumstances involved; especially if marked discrepancies between clinical findings and historical data are elicited.

  • Observation of the appearance of neglect

  • Poor or malnutrition

  • Multiple fractures or soft tissue injuries from any source including cigarette burns, or belt buckle origin

  • Unexplained head injuries


Dental Neglect
Severe dental decay in a child will not in itself be considered neglect, unless other circumstances lead the dental provider to suspect overall neglect. However, if the parent/guardian is informed of the child’s dental treatment needs and fails to complete treatment available through the [Facility] dental clinic or through CHS within a reasonable time, dental neglect may be suspected and reported.
If Abuse or Neglect is Suspected:

Provide appropriate medical care for an injury or illness that may be present.

Obtain a history from patient, parents or appropriate source.

Obtain essential laboratory test or radiological exam deemed necessary by the provider.

Contact the proper authorities


  • Social Services [Phone #]

  • County Dept. of Social Services [Phone #]


Describe Reporting and Follow Up Procedures

Example:

Dental providers will refer cases to Social Services for investigation.
OR
Dental providers will refer cases to Community Health Representatives to encourage parents tot keep dental appointments. If unsuccessful, cases will be referred to Social Services for further investigation.
OR

Dental providers will request an examination by the medical staff. The medical provider will admit the child to the hospital if it is deemed necessary for treatment or if, in their judgment, there is danger of the child being further mistreatment upon returning to the home. This also applies to the elderly.

When a child under 18 years of age is brought to the Facility and appears to have been neglected, battered or sexually assaulted, it is the responsibility of any professional person to report the incident to the [appropriate referral agency] County Department of Social Services.

The individual calling Social Services will have to give their name, but law when reporting such cases protects the individual. In reporting suspected events, give only factual information from your observation. The [Agency] is responsible for investigating and notifying a local law enforcement agency.

The hospital may retain the temporary custody of the child by order of a physician or the Hospital Administrator.
Documentation

Provider will record all pertinent information in the patient’s health record. Patient information that should be recorded: Health History, physical examination, clinical observations, history of the injury provided by all parties, laboratory tests, radiographs, and photographs of the injury. (Radiographs must only be taken when medically necessary, and never for the sole purpose of separating parent/guardian from the child to conduct separate interviews.)




  • See IHS Circular No. 64.7 (5 Mar 1982).

B.25 PATHOLOGY

PURPOSE

To establish a uniform method of performing, documenting, and informing patients of the results of tissue biopsy.

PROCEDURE



Brush Biopsy

The dentist will perform the brush biopsy according to manufacturer’s instructions. Samples are then sent to the Brush Biopsy manufacturer for analysis. Results are reported to the patients by phone or my mail if unavailable by phone. Reports are maintained in the patient’s chart.



Excisional Biopsy

Form [form #] Tissue Examination form will be completed and submitted with the tissue to the Department of Pathology at the Bethesda Naval Dental Unit, Bethesda, MD [or other appropriate laboratory]

When the report is returned from the pathologist, the dentist will initial the report and one copy will be filed in the patient’s medical/dental chart. Notation will be entered in the tissue specimen log located [in the dental clinic].

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