Body Checks for the Protection of People with Special Needs

This toolkit on body checks provides information about the importance of performing regular checks as well as tools to support the practice of body checks in the provision of care.  (A printable copy of this page can be found below).

This toolkit was created to provide information and resources to support the safety of people who require assistance to identify and report illness, injury, abuse, or neglect.

People receiving services may not be able to report pain, injury, or illness, or may not recognize abuse or neglect.  Body checks are an important tool to assess a person for these issues.  The timing and manner of conducting body checks are key to their effectiveness in safeguarding people receiving services.

Body checks can be used to determine if an injury has occurred, the extent of an injury, if there has been a change in a person's condition from the time of admission, or to obtain a baseline of information.

Body checks should be conducted routinely according to plans of care for people receiving services and after events such as falls, elopement, or restraints. Staff require training to understand the importance of completing body checks, documenting the findings, and seeking medical assistance when required. Preserving the privacy and dignity of people receiving services is also a critical component of the body check process. Sensitivity training is recommended for all staff who provide direct care as well as others involved in the body check process.

The information provided in this toolkit will help educate people receiving services, self-advocates, direct care providers, agency administrators, friends and family members on the importance of performing regular and thorough body checks.

Additional information is available for download.  Check out the Best Practices for Body Checks here. 

These case studies are offered for use in staff training and are loosely based on real Justice Center cases. The names of the people, settings, and other information have been changed.

Case Description

Mary lives at the Main Street IRA and is mainly non-verbal.  She recently had several falls at the IRA.  Staff documented the falls, completed body checks afterward, and alerted nursing to the fact that Mary was falling a lot.  Mary's nurse made an appointment for her to see her doctor and wrote a note in Mary's communication log for staff to be aware that Mary had an upcoming appointment and to remind staff of Mary's increased risk for falls.  That weekend, the Main Street IRA was staffed primarily with relief staff, some of whom had never worked there before.  Mary tripped and fell as she was walking from the living room to the kitchen.  She immediately stood up and continued to the kitchen where she used sign language to ask for some juice.  The staff poured Mary some juice, patted her on the back and said, "Glad you're okay Mary!  Did you have a nice trip?"  The staff did not document the fall, did not contact nursing about the fall and did not complete a body check to look for any injuries.  When Mary saw the doctor, he noticed that Mary had a large bruise on her knee.

Case Concerns

• Relief staff did not review the communication log and did not know about Mary's history of falls.
• Staff did not complete a body check after Mary's fall, document the fall, or alert nursing.
• Staff did not ask Mary if she was hurt.  Although Mary is primarily non-verbal, she may have been able to indicate if she felt any pain or point to a body part that hurt.
• Staff did not treat Mary with respect when they teased her about the fall.
• There were no other body checks documented for Mary in the days following her fall so staff were not aware of the bruise on her knee.

Additional case studies are available for download in the Toolkit below.  Look for Best Practices for Body Checks.

COMPLETE BODY CHECKS AS REQUIRED Follow guidance in plans of care to conduct and document body checks on people receiving services. 

ADD A PHOTO? Check agency policies for requirements or restrictions on photographing marks or injuries found during body checks. 

DOCUMENT, DOCUMENT, DOCUMENT Write clearly to ensure that fellow staff, nurses and managers will be able to read the body check form. This will save time later. 

PRACTICE SENSITIVITY Consider the person’s feelings and what they need to feel comfortable and safe when preparing to conduct a body check. 

BE DESCRIPTIVE Include details when documenting marks or injuries found during body checks. 

FILL IN THE BLANKS Complete all areas of the body check form and don’t leave any blanks. 

More detailed information on best practices for completing body checks is available in the toolkit below.  Look for Body Checks - Staff Actions.  Additional resources including agency considerations, sensitivity skills, policy guidance and a body check form are also available.