Non-Fatal Strangulation Medical Forensic Exam Note

(Use neutral, objective language: "patient reports/states." Place key patient statements in quotation marks. When information is unavailable or unclear, document "unknown," "unable to recall," "approximate," or "not obtained" rather than leaving blank or inferring. Do not state legal conclusions or causation. Document observable behaviors rather than interpretive labels. If any exam component is not performed, document the reason. Body maps are required even if photographs are declined or no visible injuries are present.)

Case Information

Date/Time: [Date and time of evaluation] Location: [Facility/department] Examiner Name/Credentials: [Name, credentials, role]

Patient Name: [Full name] DOB: [DOB] Age: [Age] Sex: [Sex as recorded]

Safe Contact Method/Restrictions: [Preferred contact number/email; restrictions, safe times; portal preferences]

Interpreter: [Language and interpreter ID, or "not required"]

Chaperone: [present / declined] [Name/role if present]

Law Enforcement Present: [yes / no] (If yes, specify which portions and officer identities.)

Patient Interviewed Alone: [yes / no] (If no, document privacy measures taken and rationale.)

Consent and Capacity

• Capacity Assessment: [Orientation, comprehension, ability to communicate a choice, understanding of risks/benefits; intoxication/cognitive limitations if any] (Document only if concerns exist; otherwise state "capacity adequate for informed consent.")
• Informed Right to Decline/Stop: [yes / no] (Document that patient was informed they may decline any portion or stop at any time.)
• Confidentiality Limits Explained: [yes / no] (Include brief note of mandatory reporting requirements per jurisdiction.)
• Mandatory Reports: [made / not made] (If made, specify agency, date/time, reference/case number if provided.)

Consent Status by Component (Indicate for each):

• Medical exam and treatment: [yes / no / declined / NA]
• Forensic documentation (written): [yes / no / declined / NA]
• Photographs: [yes / no / declined / NA] (Specify scope and anatomic regions if limited.)
• Evidence/specimen collection: [yes / no / declined / NA]
• Release of information to law enforcement: [yes / no / declined / NA] (Specify to whom and what.)
• Release of information to advocacy services: [yes / no / declined / NA] (Specify organization.)
• Follow-up contact method: [specified / declined] (Detail safe method and restrictions.)

Chief Concern and Safety Triage

[One-line summary: patient reports non-fatal strangulation approximately (time since event).]

• Immediate Safety Concerns: Assailant knows patient location: [yes / no / unknown]. Restraining order: [in place / none / unknown]. Preliminary safe discharge plan: [brief statement].
• Red Flag Checkpoint (document presence or absence):
  • Airway/respiratory compromise: [present / absent] [Details if present]
  • Neurologic deficits or altered mental status: [present / absent] [Details if present]
  • Significant neck swelling or pain: [present / absent] [Details if present]
  • Pregnancy-related concerns: [present / absent / NA] [Details if present]
  • Suicidal or homicidal ideation: [present / absent] [Details and actions if present]
• Escalation Actions: [ED transfer / imaging initiated / observation / not indicated at this time] (Specify rationale.)

Medical Forensic History

Patient Narrative: "[Patient's account of who/what/when/where and key statements about inability to breathe, loss of consciousness, threats, or feared intent]" (Use patient's own words in quotation marks for key statements.)

• Mechanism: [manual one-hand / two-hand / forearm / ligature (type) / other]. Number of episodes: [number]. Duration per episode: [approximate time]. Positions: [patient and assailant positions]. What ended the event: [description].
• Associated Violence: [head/face blows, suffocation, threats, weapons, falls, other as reported]
• Post-Event Actions Affecting Evidence: [washing, changing clothes, eating/drinking, dental hygiene, other, or unknown]

Symptom Inventory (Document "absent" when explicitly denied; "unknown/unable to recall" when uncertain.)

• During strangulation: [breathing difficulty/inability to breathe, voice changes/pain with speaking, swallowing difficulty/throat pain, neck/head pain, loss of consciousness/near-syncope, vision/hearing changes, weakness/numbness, nausea/vomiting, incontinence, behavioral changes]
• Immediately after: [as above plus: confusion/amnesia, headache, dizziness, other]
• Current: [symptoms present now; note if worsening/improving/stable; impact on activities]
• Pregnancy (if applicable): Gestational age: [weeks / unknown]. [abdominal pain, vaginal bleeding, contractions, decreased fetal movement: present / absent]

Relevant Medical History

• Allergies: [List or "none known"]
• Current Medications: [List] (Specifically note anticoagulants, antiplatelets, steroids, inhalers.)
• Past Medical History: [bleeding disorders, vascular disease, prior stroke/TIA, seizure disorder, connective tissue disorder, prior neck/thoracic surgery, other, or none]
• Pregnancy Status: [pregnant / not pregnant / unknown]
• Prior Strangulation History: [yes / no]. (If yes: frequency, most recent episode, prior medical care.)
• Substance Use: [alcohol, illicit substances, prescription misuse with timing of last use; or "none reported"] (Document as relevant to capacity and symptoms.)
• Mental Health and Self-Harm Risk: [Screening performed/not performed; findings; immediate risk assessment and actions taken]
• Primary Care Provider: [Name/clinic or unknown]

Physical Examination

• Vital Signs: BP [value], HR [value], RR [value], Temp [value], SpO2 [value] on room air, Pain [score]. (Include repeat vitals if obtained.)
• General Appearance: [Distress level, work of breathing, phonation quality, ability to manage secretions]
• Demeanor: [Observable behaviors: eye contact, speech pattern/volume/pace, tremor, crying, guarded posture] (Use objective descriptors only.)
• Head/Face/Scalp: [Tenderness, swelling, abrasions, contusions/ecchymoses, patterned marks, hair pull signs, lacerations, or "no injuries noted"] (Specify laterality and exact locations.)
• Eyes: [Conjunctival/scleral petechiae, subconjunctival hemorrhage, eyelid petechiae, ptosis, or "no abnormalities noted"]
• Ears/Nose/Mouth: [External ear findings, nasal findings, oral cavity inspection (frenula, tongue, palate, oropharynx for petechiae/abrasions), voice quality as heard during exam]
• Neck (360-degree exam including under chin): [Erythema, abrasions, contusions/ecchymoses, swelling, ligature marks, tenderness, crepitus, range of motion (if safe to assess), tracheal deviation, or "no injuries noted"]
• Respiratory: [Stridor, wheeze, breath sounds, work of breathing, chest wall tenderness, cough, or "normal"]
• Neurologic: [Mental status, cranial nerves screen, motor, sensory, coordination/gait (if safe), speech/language; focal deficits present/absent]
• Full Body Injury Survey: [Injuries beyond neck with precise locations, types, sizes; or "no additional injuries observed"] (Use body maps.)
• Deferred Components: [Component and reason] (e.g., patient declined, unsafe to perform, clinical instability) (Omit if none deferred.)

Injury Documentation

(List each injury separately. If no visible injuries in a region, document "No visible injury noted on [region] at time of exam.")

• Injury A: Type: [abrasion / contusion / erythema / petechiae / laceration / swelling / patterned injury]. Location: [exact location with laterality and landmarks]. Size: [L x W in cm]. Color/pattern: [description]. Tenderness: [present / absent]. Photo #: [numbers].
• Injury B: [As above]
• Injury C: [As above] (Add additional entries as needed.)

Body Maps: [Completed for all injuries and examined regions] (Required regardless of whether photographs taken.)

Photography

• Photo Consent and Scope: [consented / declined / limited to specific regions]
• Camera/System Used: [Device/system and secure storage method]
• Photo Log:
  • Photo [#]: [Body region], [far / mid / close], scale [yes / no], [timestamp]
  • Photo [#]: [Body region], [far / mid / close], scale [yes / no], [timestamp]
• Follow-Up Photography Plan: [Timing for follow-up photos if bruising may evolve; location/arrangements for return]

Evidence Collection

• Indication: [indicated / not indicated] [Brief rationale]
• Specimens Collected: (List each with details.)
  • [Specimen type and site], collected by [name], [date/time], patient identifiers verified, [sealed/initialed]
• Chain of Custody: Transferred from [name] to [name], [date/time]. Storage location: [location].
• If No Evidence Collected: "Not collected" [rationale, or "Not collected in this setting; patient provided referral options."]

Diagnostics and Medical Decision-Making

• Tests Obtained: [Labs, pregnancy test, imaging (CTA/CT/MRI/US)] (Include rationale tied to specific symptoms or red flags.)
• Consultations: [ENT / trauma / neurology / other] [Recommendations summarized]
• Clinical Reasoning and Disposition: [observation / admission / discharge] [Explain reasoning, particularly if airway or neurologic concerns were present]

Assessment

• Reported non-fatal strangulation: [Symptom summary; current risk status]
• Airway/voice/swallow concerns: [present / absent] [Details]
• Neurologic concerns: [present / absent] [Details]
• Soft tissue injuries: [Regions and types]
• IPV/assault context: [Document as healthcare safety concern without legal attribution]
• Risks/Differential: [e.g., vascular injury risk if tied to specific findings] (Omit if none. Avoid definitive causal statements.)

Safety Planning

• Advocate Services: [offered / accepted / declined]. Organization: [name]. Warm handoff: [completed / not completed].
• Lethality/Danger Assessment: [Tool name if used; result category only] (Omit if not performed.)
• Safe Discharge Destination: [Location and transportation plan]
• Child/Dependent Safety: [Concerns present / absent; actions taken; APS/CPS involvement if indicated]
• Safe Follow-Up Communication Plan: [Preferred method/time; risks from bills/calls/portal addressed]

Discharge Plan

• Observation Recommendation: [Someone to stay with patient for specified duration]
• Return Precautions: Difficulty breathing, voice changes, worsening swallowing, increasing neck swelling, severe headache, seizures, confusion, unilateral weakness/numbness, vision changes, chest pain.
• Pregnancy-Specific Warnings: [Pain, bleeding, contractions, decreased fetal movement] (Omit if not applicable.)
• Symptom Diary: [Advised; what to track]
• Follow-Up Plan: Forensic follow-up photos: [timing]. Medical follow-up: [primary care, ENT, neurology as indicated; appointments/referrals provided].
• Resources Provided: [Crisis/advocacy contacts; law enforcement contact if requested]
• Teach-Back Performed: [yes / no]. Written Instructions Provided: [yes / no].

Reporting and Record Handling

• Mandatory Reports: [APS / CPS / law enforcement], [date/time], reference #: [number]. (Or: "No mandatory report required; [rationale].")
• Photo Storage: [Storage location/system; access restrictions]
• EHR Protections: Sensitive-note protections: [applied / not applied]. [Additional privacy measures if any].

Examiner Attestation

Examiner Signature: [Signature or e-sign attestation] Credentials: [Credentials] Date/Time: [Date and time of attestation]