B4. Written Documentation

These recommendations are for pediatric examiners on written documentation of medical forensic care.

Ensure completion of all documentation. Examiners are responsible for documenting the medical forensic details of the examination in the prepubescent child’s medical record. All aspects of care should be documented: consent, the medical history, the examination (including written descriptions, diagram/body map rendering, and interpretation of findings), consultant reports (if done), forensic samples collected (if done), testing done and/or treatment rendered and results as available, descriptions of photographic images taken, a discharge plan, and follow-up care scheduled and referrals given.[1] Examiners also need to document this data on jurisdictional exam report forms. If examiners are called to testify in a legal proceeding, they may use this report to recall their encounter with the child (Day & Pierce-Weeks, 2013).

Document physical trauma using standard terminology and descriptive language. At a minimum, descriptions should include the type of injury (see below), but not speculate on its cause. However, if the child details the origin of an injury, it is appropriate to document her/his words in quotations. In addition to written descriptions, physical findings should be noted on body diagrams/maps and photo-documented. (See B6. Photo-Documentation) Also, samples collected from injuries should be noted.

Describing Features of Physical Injuries[2]




Use accepted terminology (e.g., abrasion, bruise, laceration, and incised wound)


Record the location/direction of wound/injury


Measure wound (using ruler)


Describe shape of wound: linear, curved, or irregular


Note condition of nearby tissue: bruised, swollen, or tender


Observe any changes in color: redness, bruising, or pallor


Note presence of foreign material in wound: dirt, debris, or glass


Note any healing injuries, such as scabbed cuts (do not attempt to date wounds)[3]


Characterize wound margins: ragged, smooth


Give an estimate of depth of wound, if present


Pattern or imprint of an object: e.g., iron, handprint, or bite mark

See www.SAFEta.org for related medical definitions.

Accurately reflect in the written record the child’s demeanor, statements made by the child during the course of care, and the caregiver’s statements regarding the history of events. All such statements, and the examiner questions, must be recorded verbatim. Such documentation can be admitted as evidence at trial in most states. (Also see B5. Medical History)

Ensure that examiners are instructed and supervised on proper written documentation. The medical record must be an accurate and thorough reflection of the examination and stand on its own (Kaplan et al., 2011). Pediatric examiners should be educated on: the importance of proper medical forensic documentation in child sexual abuse cases; the need to be objective in their documentation; the need to be consistent in documentation across these types of cases; how to access and use their jurisdictional medical forensic documentation forms; and how to document care provided in the child’s medical record. Note the following documentation “dos and don’ts:[4]



· Write or type legibly

· Complete all aspects of the medical chart

· Record the exam date and time

· Record the medical history and sources

· Record verbatim questions asked and quote patients and caregivers carefully

· Put statements by patients and caregivers in quotation marks

· Make sure duplicate copies are legible

· If you did not examine something on the form, write not examined

· Sign every page

· Complete all legally required paperwork

· Don’t leave blank sections

· Don’t cross out previously documented information

· Don’t use unauthorized abbreviations

· Don’t draw unfounded conclusions

· Don’t draw legal conclusions

· Don’t fill in the form if you are not the person who completed the examination

· Don’t use terms or phrases that have legal meaning, could be misleading in a legal case, or could be perceived as pejorative to the child[5]


Encourage examiners within an exam facility, jurisdiction, or region to devise an appropriate record review process tailored to their needs. In addition to having a system for peer review as discussed in A4a. Pediatric Examiners, consider having a clinical director or supervisor at the exam site systematically review documentation related to the examination. In some jurisdictions, review of non-physician examiner’s documentation by a medical director or supervisor is required. These reviews can serve to increase overall examiner effectiveness by ensuring that reports are completed according to policy, assessing staff training needs, considering acceptable procedures for amendments to the record, troubleshooting for potential problems, and identifying trends.

Establish policies for record storage, release, and retention. (Also see B6. Photo-Documentation) Pediatric examiners, as well as those involved in health care facility records management, should understand the record storage, release, and retention issues in these cases and if/how they differ for various populations of victims of sexual violence (e.g., prepubescent children, adolescents, and adults) and other patients receiving medical forensic care in which there is digital image documentation.   

The privacy of the child’s medical records stored at health care facilities should be protected, in accordance with applicable laws. Health care facilities should have clear policies that address secure storage and retention of paper and electronic records and that limit access to the child’s records, as well as procedures for releasing written records only to those who are legally allowed access. Mechanisms to restrict access to a child’s medical records are important in all scenarios, but particularly in small and/or close-knit communities where health care facility employees may be acquaintances, friends, and family members of patients and/or suspects. (See A5b. Confidentiality and Release of Information and A5e. Evidence Integrity)

Policies that address record storage should consider issues including but not limited to the following: How long are medical records kept in general? Is the length of time that medical records are retained different for records that involve child sexual abuse? Where are the records kept? If records are paper copies, are they kept in a locked location in files and behind doors? Who has access to those spaces? With electronic records—are firewalls used to limit access? What additional procedures are in place for photographic images? Consult with facility information technology/security and compliance departments.[6]

Facility retention policies for medical records must take into account the need for access to these records in criminal and civil proceedings.[7] There is no single standardized retention schedule that health care facilities and providers must follow for medical forensic exam records. Instead, they typically review and consider a variety of retention requirements (e.g., federal, state, and accrediting bodies) and other recommendations (e.g., from the AHIMA) when creating such a policy. Time frames for retention requirements can be relatively short (e.g., five to 10 years after the most recent patient encounter). These limited time frames can be problematic in terms of the needs of the justice system, including in cases of delayed reporting, delayed processing of evidentiary kits, CODIS hits,[8] cold case investigations,[9] conditions that extend the statute of limitations, and the appeals process. With this in mind, policies for medical forensic record retention should be based on justice standards, rather than traditional medical record keeping, storage, retention, and destruction policies. [10]

Medical records in these cases should not be destroyed.

Before information and/or photo-documentation from the child’s medical record are released for investigative purposes, it would be beneficial for pediatric examiners to educate the recipients of the information about issues such as: digital image interpretation issues, why there may be discrepancies between a child’s perception of experience and what actually happened; why there are no physical findings (if that is the case); and what symptoms might be expected with various types of anogenital contact (adapted from Kaplan, 2011).

 Table of Contents B5. Medical History

[1] Medical records from care provided related to earlier disclosures of sexual abuse to a health care provider may also be included if available and accessible (e.g., if the patient was transferred from another facility where an initial assessment of urgency of care was performed). However, inclusions of such records will vary across jurisdiction and facilities and individual cases.

[2] The chart was adapted from Day and Pierce-Weeks (2013) and WHO/UNHCR (2004).

[3] See Atwal et al. (1998).

[4] The chart was drawn from Day and Pierce-Weeks (2013) and the Massachusetts Department of Public Health (2005).

[5] For example: Don’t use legal terms such as “alleged” or “rape.” Opt for “reported sexual abuse” or “concern of sexual abuse.” Don’t use pejorative terms and phrases such as “child refuses or is uncooperative.” Opt for “child unable to complete full exam” or “child upset, tearful, crying, and/or anxious.” Don’t use medical phrases that have different forensic meaning. For example, don’t say “in no acute distress” as it may imply that the child has suffered no psychological trauma or that the examiner doubts anything happened. Don’t say “no evidence of” as there well may be evidence that is not apparent and, in many cases of substantiated sexual abuse, there are no physical findings. Don’t use “intercourse” as it may be perceived as implying consent; instead use “penetration.” Don’t use “virginal or intact” as this is misleading terminology.

[6] Also see the American Health Information Management Association’s (AHIMA) e-HIM Work Group on Security of Personal Health Information (2008) at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_039956.hcsp?dDocName=bok1_039956 for more on security issues and challenges with electronic medical records.

[7] See Ericksen and Knecht (2013) at http://victimsofcrime.org/docs/DNA%20Resource%20Center/sol-for-sexual-assault-check-chart—final—copy.pdf?sfvrsn=2 for a state-by-state comparison of statute of limitations for sexual assault and abuse.

[8] CODIS (Combined DNA Index System) describes the FBI’s program of support for criminal justice DNA databases and the software that runs these databases. For more information on CODIS, see the Federal Bureau of Investigation (n.d.) at www.fbi.gov/services/laboratory/biometric-analysis/codis/codis-and-ndis-fact-sheet.

[9] A cold case is any case whose probative investigative leads have been exhausted. See National Institute of Justice (2008) at http://nij.gov/journals/260/pages/what-is-cold-case.aspx.

[10] This paragraph was adapted in part from AHIMA (2011).