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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Assault History
General Physical Examination and Findings
Document patient’s description of the encounter in direct quotes if at all possible:
Date of assault(s)
Time of assault(s)
Physical surrounding of assault(s)
Assailant information: If more than one assailant, identify by number
Lapse of consciousness
Anterograde amnesia
Nongenital injury, pain, and/or bleeding
Anogenital injury, pain, and/or bleeding
Force or coercion used
Weapons: threatened or used
Verbal coercion, or threat(s)—(Fear of injury experienced by patient)
Physical assault
Physical restraints
Drugs used to facilitate sexual assault; clandestine drugging of patient
Ingestion of a substance (including voluntary alcohol or suspected drugs)
Injuries inflicted on assailant(s) during assault (describe)
Vital signs
Date and time of examination
General physical appearance
General demeanor/behavior/orientation—(describe the behavior, rather than label (i.e.: tearful, shaking, rather than
scared or sad)
Description of clothing on arrival
Conduct physical examination and document, draw, number injuries/findings, including size and appearance,
on a diagram (example, Figure 5) and use a legend for abbreviations or numbers (be specific)
Figure 5: Examination Drawing
Document the following acts as described by the patient and whether a penis, finger, or other object was used
Penetration of labia majora (vulva or deeper structures)
Penetration of anus or deeper structures
Oral contact with genitals
Oral contact with anus
Nongenital acts
Biting of patient or by patient on perpetrator
Oral contact (e.g. kissing)
Other acts
Did ejaculation occur? If yes, note location:
Vulva or deeper structures
Anus or deeper structures
Body surface
Contraceptives or lubricant products used
Document use of foam, jelly, lubricant, and/or condom, and the brand, if known
Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Collect reference samples per local protocol using sterile water (Module—Adult/Adolescent Patient)
Alternative light source examination
Collect dry and moist secretions, stains, and foreign materials from body, including head, hair, scalp
Examine the oral cavity for injury
Collect dried/moist secretions, stains, and foreign materials from lips, perioral region, nares
Collect fingernail scrapings or cuttings according to local policy
Gently swab the areas the suspect kissed, licked, or sucked (to limit patient’s skin cell DNA collected)
Adult/Adolescent Sexual Assault Forensic Medical Report