d. Perform medical and legal examination and collection of evidence.
e. Evaluate and treat all injures, prior to the victim leaving the emergency room.
f. Offer venereal disease and pregnancy prophylaxis (precautions taken to
prevent disease/pregnancy) to the victim.
g. Notify gynecology (OB/GYN) for female victims. Notify urology for male
victims, and notify pediatrics for children who are victims. These departments are
notified for assistance when it is necessary and required for follow up.
7-7.
RECORDING PRINCIPLES
a. Evidence. Evidence involving the suspect or suspects may also be collected.
Documenting and recording of evidence should be accomplished carefully.
Documentation and recording should follow these principles:
(1)
Document each event carefully.
(2)
Document only the pertinent medical data.
(3) Do not be involved except for gathering the medical information. (You
are not the legal authority.)
(4) In your documentation, avoid using words such as rape, assault, attack,
etc. Rape is a legal term and not a medical diagnosis. The medical team can only
determine whether sexual intercourse has occurred and if injury was sustained.
b. Records as Legal Documents. Your records are legal documents;
therefore, be sure to complete these records carefully. These records completed
incorrectly could lead to difficulties with legal actions. If you use descriptive phrases,
apply such words as alleged, and suspected instead of rape, attack, etc. When you
include patient statements, state that fact, and quote the patient as accurately as
possible.
7-8.
EVIDENCE CONTROL PRINCIPLES
The sexual assault investigation kit is used to obtain evidence. The components
of this kit are listed here:
a. Forms.
(1)
Medical Examination Report (6 pages in triplicate).
(2)
Notes to investigator.
MD0586
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