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.
Excerpt of Washington State Recommended Guidelines, Sexual Assault Emergency Medical Evaluation, Adult and Adolescent, Harborview Center for Sexual Assault and Traumatic Stress, Seattle.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.