The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach -- address acute complaints, gather pertinent historical data, describe findings, and document treatment and follow-up care; and (2) Ensuring the accuracy and objectivity of medical forensic reports by seeking education on proper report writing. (the U.S. Department of Justice, 2004) Photographic evidence of the injuries sustained by the patient may be used to supplement the medical forensic history and to document findings of a physical nature. The U.S. Department of Justice states that following recommendations in the area of photographic documentation: (1) Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, while others limit photography to detected injuries; (2) Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation as well as educated in forensic photography and in ways to maintain the patient's privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used; (3) Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses of photographs during investigation and prosecution, and the possible need for follow-up photographs; (4) Consider the patient's comfort and need for modesty. • Identify who will be present when photographs are taken; and (5) Take initial and follow-up photographs as appropriate, according to jurisdictional policy.
VII. Evidence Collection Procedures
In relation to exam and evidence collection procedures, the U.S. Department of Justice states that jurisdictional policy is the guidelines that examiners look to in collecting evidence. Recommendations made for exam and evidence collection procedures include the following: (1) Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions; (2) Be aware of evidence that may be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested; (3) Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence; (4) Understand the implication of the presence or lack of semen (in cases involving male suspects); (5) Seek informed consent from patients for each portion of the exam and evidence collection; (6) Modify the exam and evidence collection to address the specific needs and concerns of patients; (7) Conduct the general physical and anogenital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient's consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence; (8) Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy; (9) Collect blood and/or urine for toxicology screening, if applicable; and (10) Keep medical specimens separate from forensic specimens collected during the exam. (U.S. Department of Justice, 2004)
VIII. Sexual Assault Facilitated Through Drug
The health care provider, whether it be a nurse or a medical doctor must give consideration to the possibility that the individual may have been drugged in order for the perpetrator to facilitate the assault. Recommendations stated by the U.S. Department of Justice includes education of all responders in this area as well as obtaining informed consent from patients when testing their urine. When the patient provides permission, urine samples should be immediately collected if ingestion of drugs for facilitation of the assault is suspected. If the ingestion of drugs for facilitation of sexual assault was within 24 hours of the exam a blood sample should be collected as well.
IX. STIS and STDS
Sexually transmitted disease or infection evaluation and care is addressed as well by the U.S. Department of Justice which include the following: (1) Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, follow-up care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended; (2) Consider testing patients for STIs during the initial exam on a case-by-case basis. If testing is done, follow the guidelines...
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