During a routine visit, a patient presents with a black eye and mentions getting hit by a stray ball during a community baseball game two days prior. The patient laughs it off but appears slightly uncomfortable discussing the incident. While accidental sports injuries are common, something about the patient’s demeanor raises your concern. What is the most prudent action for a medical assistant to take in this scenario?
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Carefully document the patient's stated cause of injury and observe for any patterns or inconsistencies in future visits.
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Advise the patient on the improbability of their explanation and encourage them to admit to being a victim of violence.
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Immediately report the injury to law enforcement on suspicion of domestic abuse without further verification.
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Dismiss the patient’s explanation and insist on a full body examination for other signs of abuse, disregarding their comfort and consent.
When an injury could reasonably be accidental, and the patient provides a plausible explanation, a medical assistant should document the patient’s explanation in detail. Although medical assistants should be vigilant for signs of abuse, reporting an injury caused by an accident at a sports event, especially with a plausible explanation provided, isn't typically mandated. However, careful documentation is essential to establish the patient's version of events should questions arise later, and should a pattern of injuries emerge over time, documentation would be critical for any subsequent reporting. Attempting to report without sufficient cause may lead to a breach of trust and confidentiality. It is also important to maintain a nonjudgmental and supportive demeanor, allowing the patient to feel safe in disclosing any future concerns.
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