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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Chapter 8
Documentation
Tiffany Bombard, BA, NREMTP and Shellie Asher, MD, MS
Documentation of the assessment of the sexual assault victim by the sexual assault examiner should cover the usual
History of Present Illness, Past Medical History, Physical Exam, Assessment and Plan components of a patient
encounter. Descriptions of the assessment should be thorough and easy to interpret by both medically trained and
non-medically trained persons, and as is good medical habit, all documentation by the sexual assault examiner should
be completed in an unbiased manner.
Accounts of Victims or Witnesses
Gathering an account of the sexual assault (history of present illness) is standard medical practice and is of particular
importance to the sexual assault examiner if the patient’s condition prevents their interview by law enforcement. In
these cases, if the patient dies or is incapacitated, the sexual assault examiner may be the only person able to testify
to the patient’s account of the assault. When possible, however, it is advantageous for the forensic examiner and law
enforcement to simultaneously interview the patient regarding the events surrounding the assault. This practice is
helpful not only because the police are a proper resource for documenting the patient’s description of the crime but
because police officers have continuous practice in conducting and documenting patient histories which are used in
court.
Additionally, allowing the police officer to witness this portion of your interview helps to prevent the creation of
two differing renditions of the patient’s story (the sexual assault examiner’s and the investigating police officer’s).
Presentation in court of two similar but not exactly matching accounts of the incident can erode the credibility of
examiners and investigators as well as that of the victim and should be avoided if possible.
There are several components of the history of present illness that the sexual assault examiner should be sure
to include in any interview. They are perhaps best recalled if one thinks chronologically about the event. If any
information is gathered from someone other than the patient (for example a witness or family member) then the
identity of the source should always accompany the information provided.
Past Medical History
• Has the patient had any past anogenital surgery?
• (If female) what is the patient’s OB/GYN history (term pregnancies, premature births, abortions/miscarriages,
live births)?
— Is the patient pregnant?
— When was her last menstrual period?
— History of sexually transmitted infections?
• Is there history pertinent to whether the patient could give consent? For example, does the patient have a history
of brain injury, mental retardation or dementia?
• What was the date and time of the patient’s last consensual sexual encounter and what method(s) were used (for
example, oral, anal, vaginal)?
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Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Documentation
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