Provider Agency Best Practices for Completing Body Checks

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.

Policy & Procedure

Review policies and procedures to ensure they provide clear guidance on how and when to complete body checks. Ensure policies address the importance of preserving the dignity and rights of people receiving services during this process. Provide staff practical guidance on how to respond if a person does not agree to undergo a body check. Address requirements for photographing marks or injuries and provide guidance for staff to use agency issued equipment for taking or transmitting photographs of people receiving services.

Medical Care

Train all staff to access nursing supports or other medical care such as a primary care physician or urgent care if needed when marks or injuries are discovered during the body check process. Provide training to staff on signs and symptoms of illness to assist staff in recognizing marks, bruises, or injuries that require medical attention.

Forms

Use a body check form that has clear directions for completing and documenting the body check. Ensure the form instructs staff to answer questions and fill in blanks to capture as much information as possible. Structure the form to record whether marks or injuries are new or previously noted, the worsening or healing of previously identified marks or injuries, and whether a whole or partial body check was completed. Include a space on the form for staff to describe their findings.

Click here to download our sample body checks form

Documentation Review

Review body check documentation on a regular basis to ensure it’s thorough, accurate, and completed as required by plans of care. Provide support to staff who may need additional training or follow up to thoroughly document body checks.

Training

Provide comprehensive training to staff on the importance of completing body checks and the role they play in safeguarding people receiving services. Incorporate specific sensitivity skills into training to help safeguard privacy, dignity, and respect for people receiving services during this process. Train staff to recognize when marks or injuries found may be a sign of abuse or neglect and require reporting to the Justice Center.

Our Spotlight on Prevention Toolkits are dedicated to educating providers, individuals, and families on proper care for individuals receiving services. Download the full Spotlight on Prevention: Best Practices for Body Checks below. 

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