What to document for sexual assault

Patient Information

In addition to routine registration data, document:

  • Person who accompanied patient and relationship to patient
  • Police report if filed: police department and case number

History of Assault

Facts about assault:

  • Source of information (patient, police, or accompanying person)
  • Time and place of assault
  • Hours since assault
  • Number of assailants and sexual assailants, relationship to victim, and identity if known
  • Brief narrative history of assault

Nature of force used:

  • Patient had impaired consciousness
  • Known or suspected drug or alcohol ingestion
  • Verbal threats
  • Perceived life threat
  • Use of physical force
  • Use of weapon

Physical facts of sexual assault:

  • Which orifices assaulted
  • By what (finger, penis, mouth, foreign object)
  • If condom was used
  • Physical injuries
  • Sites where assailant’s saliva may be on victim
  • If ejaculation was noted, and where

Post-assault activity:

  • Showered, bathed
  • Douched, rinsed mouth, urinated, defecated
  • Changed clothes, gave clothes to police at scene, or brought clothes worn at time of assault to emergency department

Risk factors of assailant regarding hepatitis B, syphilis, and HIV if known:

  • Known or suspected intravenous drug use
  • Man who has had sex with men
  • Assailant from an endemic country

Source: Excerpt of Washington State Recommended Guidelines, Sexual Assault Emergency Medical Evaluation, Adult and Adolescent, Harborview Center for Sexual Assault and Traumatic Stress, Seattle.