Examination Process- Initial Contact

Download this section- Documentation by Health Care Personnel

Documentation by Health Care Personnel

Recommendations at a glance for completing needed documentation:

  • Ensure completion of all appropriate documentation.
  • Educate examiners on proper documentation.
  • Ensure the accuracy and objectivity of medical forensic reports.

Ensure completion of all appropriate documentation.

Examiners are responsible for documenting the details of the medical forensic exam and treatment provided in the medical record, as well as documenting required data for the evidence collection kit, according to jurisdictional policy. This evidence collection kit report usually includes patient consent forms related to evidence, the history of the assault, and information pertaining to evidence collection that will assist the crime lab in material identification for analysis. 1 (The medical forensic history and documentation of exam findings are discussed in more depth in later chapters in this section.) The only medical issues documented in this report are findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. If the case is reported, the criminal justice system will use the entire medical forensic record of the sexual assault visit, along with collected evidence, photographs and video images, and victim/witness statements, as a basis for investigation and possible prosecution. If examiners are required to testify in court, they will use the report to recall the incident.

The overall medical forensic record kept by examiners and other clinicians follows a standard approach of addressing acute complaints; gathering pertinent historical data; describing physical findings, laboratory and x-ray findings, consultation reports (if done) and evidence collection procedures; and documenting treatment (and response to treatment) and follow-up care. The complete medical forensic record of the sexual assault visit should be maintained separately from the patient’s medical record to limit disclosure of unrelated information and to preserve confidentiality. The medical record is stored at the exam site. The exam site should have clear policies about who is allowed access to these records.2

The medical record is not part of the evidence collection kit and it should not be submitted to the crime lab or given to law enforcement. Much of the record is not relevant to case prosecution, and releasing it infringes upon patients’ privacy rights. Although all or part of the medical record may be subpoenaed, if patients do not consent to its release, it is ultimately up to the court to decide whether such information is pertinent to the case and should be released.

Ensure the accuracy and objectivity of medical forensic reports.

It is suggested that examiners within an exam site, jurisdiction, or region devise an appropriate review process tailored to their needs. Consider having a clinical director or supervisor at the exam site systematically review documentation related to the exam. (In some jurisdictions, review of nonphysician examiner’s documentation by a medical director/supervisor is required.) These reviews can serve to increase the overall effectiveness of the examiner program by ensuring that reports are completed according to policy, assessing staff training needs, considering adjustments needed to paperwork, troubleshooting for potential problems, and identifying trends in presenting the issues of patients. All identifying patient information should be removed when a document is copied for a review. The clinical director or supervisor can also be involved in broader multidisciplinary quality assurance efforts related to the exam process.

 Table of Contents The Medical Forensic History



1 Documentation of exam findings should include patients’ demeanor and statements related to the assault not already recorded on the medical forensic history. Such documentation can be admitted as evidence at trial in most states. Local prosecutors can provide more detailed information on this type of documentation.

2 Mechanisms to restrict access to records related to the exam are particularly important in small communities where exam site employees may be acquaintances, friends, and family members of patients or suspects.