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WellSpan Health Forensic Medical Record
York Hospital
Gettysburg Hospital
Adult/Adolescent
Form 4431 5/2012
WellSpan Health Forensic Medical Record
York Hospital
Gettysburg Hospital
Adult/Adolescent
Form 4431 5/2012
Sexual Assault Evidence Collection Kit
Collection Envelopes provided in Evidence Collection Kit
Done
□
Not Done
□
Step 3: Oral Assault Collection Samples
If not done, why?_____________________________________________
_________________________________________________________________
□
□
Step 4: Miscellaneous Collection (Debris, Dried Secretions, Tampon/
Sanitary Napkin)
If not done, why?_____________________________________________
□
□
Step 5: Fingernail Clippings/Scrapings
If not done, why?__________________________________
□
□
Step 6: Pubic Hair Combings
If not done, why?_____________________________________________
_________________________________________________________________
□
□
Step 7: Vaginal Assault/Penile Assault Collection Samples
If not done, why?_____________________________________________
□
□
Step 8: Rectal Assault Collection Samples
If not done, why?_____________________________________________
_________________________________________________________________
□
□
Step 9: Buccal Swab Collection
If not done, why?_____________________________________________
_________________________________________________________________
□
□
Step 2: Foreign Material/Clothing and Underpants Collection
If not done, why?_____________________________________________
_________________________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
B
BR
BL
BI
BU
AB
AV
LA
DE
Bruise
Bleeding
Bitemark
Burn
Abrasion
Avulsion
Laceration
Deformity
S
SW
ST
TE
TR
ER
PA
PT
PE
Swelling
Stain (+FL if fluorescent)
T
Tenderness
Trace Evidence
A
E
Erythema
P
Patterned Injury
L
Petechiae
D
Penetrating Injury
I=incised S=stab
P
Puncture
Draw shape, use initials & size, color, shape (e.g. “BR red oval 3cm H x 2cm W)
Carter-Snell, C. (2011) http://mtroyal.ca/forensicresearch. (see “resources” section) May be copied.
Initials________/Date_______
148 Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Page 22 of 28
Initials________/Date_______
Page 23 of 28
Appendices
149