Assessment, Interview, and Documentation with Forensics, comment


As a nurse, I agree that physical as well as emotional assessment is vital in completing a thorough assessment. I believe just looking at the patient when entering the room is a big part of assessing them along with actually doing a physical assessment. Time should be taken to do a thorough assessment just by speaking to the patient because it gives you more information and insight. It can also lead to more answers with abnormal findings with a physical assessment, such as increased heart rate due to stress, for example. Subjective information should be documented as the patient describes the events. This protects the nurse legally. I have learned in my career that this is essential in performing thorough and accurate assessments.

Original Post:
September 26, 2007
Forensic nursing was traditionally associated with death and homicide. Today forensic nursing can be defined as the application of nursing as it overlaps with the legal system. Nurses have been taught how to perform a health assessment with history and physical examination. This includes subjective and objective findings. Good assessment skills by the nurse are important to detect both physical and emotional abuse. This is accomplished with the first interaction the nurse has with the patient.
Accurate documentation is imperative. Record direct quotes as often as possible. Avoid using medical terminology, correcting the patient’s grammar or paraphrasing the patient’s descriptions.
A unique concept of forensic assessment is alternate interviewing techniques. One such method is the “forensic genogram”. This is expanded from the traditional genogram, and includes information about the transmission of family patterns, including violence. Understanding family influences assists in understanding events that may have led to the abusive behavior.



%d bloggers like this: