Medical Forensic History-Taking and Documentation of the Medical Forensic Examination

As stated in the National Protocol for Sexual Assault Medical Forensic Examinations, "(T)his history, obtained by asking patients detailed forensic and medical questions related to the assault, is intended to guide the exam, evidence collection, and laboratory analysis."⁷⁶ 

Many states have standardized sexual assault examination forms. It is important to understand that the location of a SANE program may influence the content of a standardized examination report form. For a patient evaluated in an emergency department, the provider who performs the initial medical screening examination may obtain information such as chronic medical problems and medications from the patient. While the nurse providing the sexual assault examination should review this information prior to commencing care, it may not be necessary to repeat those questions as part of the SANE's evaluation. For a SANE providing care in a community setting, obtaining a history of current medical conditions is necessary in order to give safe care. For example, if a patient has a history of a seizure disorder, the nurse will need to assess the patient for anti-epileptic medication use and the risk for a seizure being triggered before, during, or after the examination. 

When creating or revising a form, it is important to decide how the information will assist in the care of the patient. Recognizing community uniqueness means realizing that different states and different communities may create forms with different content. Members of the multidisciplinary team should be consulted during the development of a form. For example, the crime lab may use the descriptions of the type of evidence collected to determine what type of analysis will be employed. Prosecutors may use the descriptions of the type of contact described by the patient to determine what criminal charges will be filed against the suspect. While input of team members is important, the goal of a form is ultimately to assist the nurse in providing comprehensive and safe health care to the patient, which includes identifying any sites of injury or locations where medical forensic evidence can be collected.

Below is a list of suggested content for a sexual assault examination form.

1. Chief complaint – including acute complaints of pain or bleeding.
2. Allergies to medications, food, and latex.
3. Current medications.
4. Pertinent medical history, recent anal-genital injuries, surgeries, or diagnostic procedures, blood-clotting history, and other pertinent medical conditions or treatment.⁷⁷  
5. Reproductive history – LMP, vaginal deliveries, age of first menses.
6. History of assault – time, date, location, and what occurred. 
7. Acts that demonstrate threats or lack of consent – use of weapon, restraints, strangulation, or verbal threats.
8. History of drug or alcohol use prior to or during the assault.
9. History of loss of consciousness or awareness.
10. Details of all physical contact, including genital or oral contact.
11. Post-assault hygiene.
12. Recent consensual sexual activity (important for issues on DNA recovery, as well as pregnancy implications for the victim).

This is not an exhaustive list, but it includes many of the topics that are typically covered by state or jurisdictional sexual assault examination forms. It is important to get enough medical history to make sure the SANE can provide safe care and treatment. For example, some nurses feel documenting the use of an antidepressant may later be used to imply the patient is mentally ill or making up the assault. As a health care provider, the SANE must put the health care needs of the patient first, and make sure the patient is not at risk for suicide or other self-harm. Knowing about antidepressant or other medication use informs the nurse with regard to risk of subsequent problems or potential interactions with medications that may be offered at the time of the exam. 

Children and Patients With Cognitive Disabilities

The medical forensic history-taking of a child or an adult with a cognitive disability, like all other patients, is a critical component of the examination. In some cases, the patient may use nonverbal communication, in other cases, the child or adult may be at a developmental level incapable of obtaining a successful or accurate history of event (e.g., a child under 4 years of age), requiring the history be obtained from other parties, such as the nonoffending parent, caregiver, or other witness. While SANEs should not be held to the standard of forensic interviewers, experience and training in developmentally appropriate history-taking and familiarity with strategies to enhance understanding and engagement of people with cognitive disabilities is important. 

Accompaniment During an Examination 

It is appropriate to allow the patient to have a support person with them throughout the examination. Who that support person is will help determine their role in the examination.

1. Victim advocates. A victim advocate can provide support, and in many cases, can provide the added benefit of offering comprehensive, longer term services to aid the victim. In many communities, they are an essential component of the SART. Typically, community-based advocates are able to speak with the patient with a greater degree of confidentiality (which can be jurisdictionally dependent).
2. Family members. Although family members may be supportive of the victim, they should not be relied on to provide emotional accompaniment during the examination. It should be recognized that family members might also be experiencing emotional trauma and distress related to the assault. Recognize that if the patient does prefer a family member to be with them during the exam, both should be aware of the implications of that. It will be necessary to inform them that they may potentially be required to testify in criminal justice proceedings as a witness. The patient may also be reluctant to disclose the details of the assault in the presence of family members, and the patient should be informed that some of the questions asked during the exam will be intimate in nature. In some cases, the family member may be the offender. When the patient is a minor, the child should still be asked if they would like a support person in the exam room with them. As another option, the patient may want the supportive individual in the room for the exam, but not while the history is being obtained.
3. Personal care attendants. A personal care attendant may accompany some patients with disabilities. It should be the patient's choice whether or not the attendant is present during the examination, unless there is a concern the personal attendant is the suspected offender.