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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
History of the Present Illness
Physical Examination
• Was there drug or alcohol use by the patient before, during,
or after the assault?
• Where and when did the assault take place?
• Was there touching or penetration of any part of the patient’s
body with a penis, finger or any object?
• Was a condom used?
• Was there use of any kind of spermicidal foam or gel?
• Is the patient using any other form of birth control
(IUD, oral, etc.)?
• Is the patient undergoing fertility treatment?
• Was the patient kissed, licked or bitten by the assailant,
and if so where?
• Did the patient clean up in any way after the assault?
Specifically, did the patient:
— void
— insert or remove a tampon
— change a sanitary pad
— shower, bathe, douche, wipe
— change clothes
— brush their teeth, gargle, chew gum, smoke, eat, drink or
A regional system of documentation with headings such as: HEENT, NECK, CHEST, BACK, ABDOMEN, PELVIS,
GENITAL, RECTAL and EXTREMITIES followed by LABORATORY VALUES, RADIOGRAPHIC STUDIES and
PHOTOGRAPHS may be more useful than is a system-based description of the physical exam, as it often better
documents trauma and is easily interpreted by persons without medical training. When using this system, there are
also some general reminders that may also be of help.
• When documenting the genital examination, include the patient’s Tanner stage (see the “Pediatric/Adolescent
Patient” section of this handbook for a description of the Tanner stages).
• When describing the location of wounds, use nearby anatomic landmarks and, when pertinent, describe the
wound shape. Examples of descriptions are: paired, directional, patterned (as from a clothes iron, belt, tool, teeth,
car grille), or colored (ruborous, ecchymotic).
• When describing a contusion, a simple description of size, shape and location is best. Never judge the age of
ecchymosis by its color.
• When describing gunshot wounds, include observations of muzzle imprints, abrasion collars, tattooing, abrasions
and soot on the skin if they are found, however DO NOT SPECULATE ON EXIT AND ENTRANCE WOUNDS or
on weapon caliber.
• A laceration is a skin tear from a blunt object. Cuts, incisions, stabs, slices and slashes come from sharp objects.
• Use the “Bite Mark Guidelines” section of this handbook to help with documentation of bite marks.
• Comparison to a clock face is a particularly good description method for perineal injury. Include patient position
(e.g. “0.5 cm anal abrasion at 3:00 position with patient supine”).
• To prevent discrepancies, always use a ruler or another known standard, such as a coin, to document size of
wounds. Do not estimate.
• Include a ruler in all wound photographs, and make sure to take both detail (close up) and perspective (farther
away) photographs to illustrate the location and extent of the injuries. Recheck the photographs before releasing
the victim for admission/discharge to make sure that they are in focus and illustrate the injuries well. You only
get one chance to get these right. Copy and save any photographs to an alternate device immediately to avoid
accidental loss/deletion. (Please see the section of this guidebook titled “Medicolegal Photography in Sexual
Assaults”.) Consider having the patient return for additional photographs as additional injuries may appear.
• Correlation of the description of injuries or findings of moist secretions with representation on a body or genital
map diagram is also very useful (please see the “Child/Adolescent” and “Adult/Adolescent Sexual Assault
Forensic Medical Report” example sheets for guidance).
• Document the presence of colposcope photographs/video if a colposcope is used. (Please see the section of this
guidebook titled “Use of Colposcope”).
— take medications before coming to the ED?
If so, when? Where are the original clothes, sanitary pads, or cleaning accessories?
• Who brought the patient to the ED?
— What are the names and agencies of the EMS providers or
— The name and contact information of any stranger, friend or family member who accompanied the
patient to the hospital?
The answers to the above questions are not only pertinent to an eventual legal case, but should also be used by
the sexual assault examiner to help guide the physical examination and by the police department to help guide
the crime investigation. The usual manner of a legal proceeding in court is to have the victim describe the
event and identify the assailant if possible. With this said, the sexual assault examiner’s account of the victim’s
statements is sometimes admissible in court, particularly when it was obtained in the standard practice of
patient care, for example the victim’s description of how an injury was sustained: “That bruise was from when
I was hit with the butt of a gun.”
Rarely, the examiner’s recount of a victim’s identification of a specific assailant “Jane hit me” is also admitted.
Documentation of these statements by the sexual assault examiner should be word for word and enclosed by
quotation marks. Again, if the patient is able to give this information directly to law enforcement as well, this
is ideal.
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Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Diagnostic Studies
Should radiographs be used, comment should be made in your report regarding the location and size of bullets and/or
foreign bodies, but no speculation should be given as to caliber.
Note which laboratory tests and toxicology screens were sent even though results might not be available at the time of
your documentation.
Assessment and Plan
The assessment and plan is used to summarize the medical provider’s findings and treatment plan. In cases with
clear physical evidence, this can be an area to summarize injuries and other physical findings, and outline the plan for
treatment including treatment for pregnancy and sexually transmitted infections including HIV. Do not be afraid to
document a normal physical exam. In cases without clear physical evidence, a summary statement such as “history
and exam consistent with sexual assault” can be helpful in clarifying that a normal physical exam does not preclude
the possibility of sexual assault.
Documentation
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