Sexual Abuse Medical Forensic Exam Note (Pediatric/Prepubescent)

(This template is for pediatric/prepubescent sexual abuse medical forensic examinations. Use neutral, objective, clinically precise, patient-first language throughout. Do not use legal conclusions or terms such as "rape," "molestation," or "perpetrator." Avoid misleading phrases such as "intact," "virginal," "no evidence of," or "NAD." Attribute each history element to a source. If information is unavailable, state "Unknown," "Unable to obtain," "Not examined," or "Not applicable" with reason. Document times for consent, exam start/end, evidence collection/transfer, mandatory report, and discharge.)

Header Metadata Block

Patient Name: [Patient full legal name]
MRN: [Medical record number]
DOB / Age: [Date of birth] / [Age in years and months]
Sex Assigned at Birth: [Female / Male / Intersex / Unknown]
Guardian Name / Relationship: [Name and legal relationship]
Date of Exam: [Date]
Exam Start Time / End Time: [Start time] / [End time]
Exam Type: [Acute with evidence collection / Acute without evidence collection / Non-acute]
Location: [Facility name and type]
Examiner Name / Credentials: [Name and credentials]
Chaperone Name / Role: [Name and role]
Interpreter: [Yes - name/ID and language / No / Not applicable]
Referral Source: [Self / Caregiver / CPS / Law enforcement / Healthcare provider / Other]
Law Enforcement Agency / Case Number: [Agency and case number if known]
CPS Intake Number: [Number if known]

Consent and Assent

(Mark each element as Obtained / Declined / Not Applicable. Document who provided or declined consent and rationale. For declined elements, document alternatives offered. If guardian is absent, suspected of involvement, or not acting in child's best interest, document the legal mechanism used to proceed.)

• Legal Consent Provided By: [Parent/guardian / Protective custody authority / Court order / Other] — [Obtained / Declined / Not Applicable] — [Notes]
• Child Assent: [Obtained / Declined / Unable to assess due to age or development] — [Notes]
• Child Informed They May Pause or Stop at Any Time: [Yes / No] — [Notes]

Consent Elements:

• Medical evaluation and treatment: [Obtained / Declined / Not Applicable] — [Notes]
• Head-to-toe physical examination: [Obtained / Declined / Not Applicable] — [Notes]
• Anogenital examination: [Obtained / Declined / Not Applicable] — [Notes]
• Photo documentation (general injuries): [Obtained / Declined / Not Applicable] — [Notes]
• Photo documentation (anogenital): [Obtained / Declined / Not Applicable] — [Notes]
• Forensic evidence collection: [Obtained / Declined / Not Applicable] — [Notes]
• STI testing: [Obtained / Declined / Not Applicable] — [Notes]
• HIV testing and nPEP discussion: [Obtained / Declined / Not Applicable] — [Notes]
• Toxicology collection: [Obtained / Declined / Not Applicable] — [Notes]
• Information sharing per mandatory reporting requirements: [Obtained / Declined / Not Applicable] — [Notes]

Confidentiality and Mandatory Reporting

[Documentation that confidentiality and its limits including mandatory reporting were explained to caregiver and child in developmentally appropriate terms]

• Mandatory Report Made: [Yes / No / Pending]
• Agency Contacted: [CPS hotline / Law enforcement / Both]
• Date/Time of Report: [Date and time]
• Contact Person / ID: [Name or ID]
• Summary of Information Reported: [High-level summary]

Notifications/Coordination: [CAC involvement, advocate involvement, social work, child life, specialty consults] (Note whether law enforcement or CPS were present during history-taking or exam and reason.)

Medical Forensic History

Sources: [Child direct report / Non-offending caregiver / Prior forensic interview summary / Referral information / Chart review] (Note limitations such as preverbal child, interpreter used, developmental considerations, emotional state affecting participation.)

Chief Complaint: [Patient-centered reason for visit with source attribution]

History of Present Illness: [Narrative summary including: date/time of last suspected contact or range; whether bodily fluid contact reported; symptoms since event; activities since event potentially affecting evidence; current safety situation] (Use quotation marks for child's exact words. Attribute details to sources.)

Event History (Medical-Forensic Focus):

• Type of contact reported: [Genital-genital / Oral-genital / Anal / Digital / Object / Non-contact exposure / Unknown]
• Body sites involved: [Sites]
• Use of force, threats, or restraint: [Yes / No / Unknown] — [Details if disclosed]
• Suspected drug/alcohol facilitation: [Concern present / None disclosed / Unknown]
• Known vs unknown person: [Known / Unknown] (Include only details relevant to medical/STI risk assessment.)

Past Medical History: [Current diagnoses including dermatologic, GI/GU conditions; prior surgeries/trauma; GU history; bleeding disorders; developmental history relevant to communication/exam tolerance; mental health history] (Attribute to source.)

Medications: [Current medications including topical agents] (Attribute to source.)

Allergies: [Allergies and reactions / None known / Unknown] (Attribute to source.)

Immunizations: [Hepatitis B status; HPV vaccine status if age 9+] (Attribute to source.)

Social History: [Household composition; school/daycare; prior CPS involvement if known; other children potentially at risk and documentation that concern was communicated to appropriate agency] (Attribute to source.)

Review of Systems: (Attribute to source.)

• General: [Findings]
• GU (external genital): [Findings]
• Anal/Rectal: [Findings]
• Oral: [Findings]
• GI: [Findings]
• Dermatologic: [Findings]
• Neuro/Behavioral: [Findings]
• Other systems as relevant: [Findings]

Physical Examination

Vitals: [HR, RR, BP if obtained, Temp, SpO2, Weight, Height, Pain score with scale used]

General Appearance: [Overall appearance and behavior in neutral terms]

Head-to-Toe Exam: (For injuries, document type, precise location, size with measurements, shape/borders, color, tenderness, and foreign material.)

• Head/Face/Neck (including oral cavity): [Findings / No acute findings identified / Not examined - reason]
• Skin: [Findings / No acute findings identified / Not examined - reason]
• Chest: [Findings / No acute findings identified / Not examined - reason]
• Abdomen: [Findings / No acute findings identified / Not examined - reason]
• Back/Buttocks: [Findings / No acute findings identified / Not examined - reason]
• Extremities: [Findings / No acute findings identified / Not examined - reason]
• Neurologic: [Alertness, orientation appropriate to age, gross motor/sensory]
• Tanner Stage: [I / II / III / IV / V]

Anogenital Examination:

• Persons Present: [Chaperone / Caregiver / Child life / Other]
• Positions Used: [Supine frog-leg / Prone knee-chest / Lateral decubitus / Other]
• Techniques: [Labial separation / Labial traction / Saline float / Gentle gluteal separation / Other]
• Magnification/Equipment: [Colposcope / Camera / Lighting / None]
• Exam Limitations: [None / Limited by tolerance - specify components completed and not completed]

(Use clock-face notation for anatomic localization and state the convention used. Do not attempt to date injuries based on appearance.)

• Female structures: [Mons pubis, labia majora/minora, clitoral hood/clitoris, urethra/periurethral area, vestibule, fossa navicularis, posterior fourchette, perineum, hymen - findings by structure with clock-face and measurements]
• Male structures: [Penis including glans/frenulum/meatus/shaft, prepuce if present, scrotum/testes, inguinal region, perineum - findings by structure with clock-face and measurements]
• Anal/Perianal: [Perianal folds, anal verge/margin, gluteal cleft, presence of stool, fissures, dilation - findings with clock-face and measurements]

[Documentation that findings were rendered on body maps including general body map and focused anogenital diagrams]

Photo Documentation

• Photos Taken: [Yes / No / Partial - specify]
• Consent for Photos: [Yes - from whom / No / Partial - specify]
• Equipment Used: [Camera/colposcope details]
• Chaperone Present: [Yes / No]
• Child Tolerance: [Tolerated well / Limited - specify / Unable to tolerate - reason]
• If Not Done or Limited: [Reason]

(Photograph both injuries and normal anatomy when applicable. Obtain photos before cleaning/swabbing when feasible. Use three-distance approach: orientation, mid-range, close-up with scale.)

Photo Log: [Number of images; body regions captured; whether scale was used]

Forensic Evidence Collection

• Evidence Collection Performed: [Yes / No]
• Rationale: [Time since event, potential for biological/trace evidence, child assent, jurisdictional time window]

(If performed:)

• Kit Type / Number: [Type and number]
• Collection Start Time / End Time: [Start time] / [End time]
• Items Collected: [Itemized list with site, collector initials, date/time, packaging method, seal number for each item]
• Kit Steps Not Performed: [Step and rationale for each]
• Chain of Custody: [For each transfer: date/time, person releasing, person receiving with name/ID, seal condition]
• Evidence Sealed and Transferred To: [Agency/person, date/time]

(If evidence collection not performed, document rationale.)

Laboratory Testing (Medical Specimens)

(Medical specimens do not require chain of custody.)

• STI Testing:
  • Indication: [Symptoms / Disclosure / Inability to verbalize details / Caregiver request / Other]
  • Sites Tested: [Urine / Vaginal swab / Pharyngeal / Rectal / Other]
  • Test Type: [NAAT / Culture / Other]
  • Confirmatory Plan: [Plan for any positive result]
• Serology Collected: [HIV / Syphilis / HBV baseline / None]
• HIV Risk Assessment and nPEP: [Risk factors discussed; nPEP recommendation; if started - baseline labs and follow-up plan]
• Pregnancy Testing: [Not applicable for prepubescent / Performed due to unclear pubertal status - result]
• Pending Results: [Tests pending and safe communication plan]

Treatments and Interventions

• Wound Care: [Description]
• Pain Management: [Medication, dose, route, time]
• Medications Administered: [Medication, dose, route, time]
• Medications Prescribed: [Medication, dose, frequency, duration]
• STI Treatment: [Presumptive treatment provided / Deferred - rationale]
• Supportive Interventions: [Advocate, child life, social work, crisis intervention involvement]

Consultations

• [Service/Consultant] — [Date/Time] — [Key recommendations]

(Add additional consultations as needed.)

Assessment

• Reported Concern: [Summary with source attribution]
• Symptoms: [Summary]
• Exam Findings Summary: [General and anogenital exam highlights; note limitations]
• Evidence Collection: [Performed / Not performed - rationale]
• Photo Documentation: [Completed / Partial / Not done - rationale]
• Labs: [Collected / Pending / Follow-up plan]
• Safety: [Current living situation; alleged person access; immediate concerns]

Interpretation of Anogenital Findings: [Normal exam with no acute injury identified / Nonspecific findings / Findings concerning for trauma / Findings diagnostic of trauma]

[Limitations such as timing since contact, incomplete history, or limited exam] A normal anogenital examination does not confirm or exclude sexual abuse, as physical findings may be absent even in confirmed cases.

(For nonspecific findings, document relevant differential diagnoses such as dermatitis, vulvovaginitis, or constipation-related fissures.)

Discharge and Safety Planning

• Discharge Summary Reviewed With: [Caregiver / Child as appropriate]
• Questions Answered / Understanding Confirmed: [Yes / No]
• Disposition: [Home with caregiver / Alternate caregiver / Foster placement / Admission]
• Alleged Person Access: [No access / Has access - mitigation steps]
• Immediate Safety Concerns and Steps Taken: [Details]
• Safety Planning Assisted By: [Advocate / Social work / CPS / Law enforcement]
• Medical Follow-Up:
  • Healing exam if injuries present: [Date/location]
  • STI follow-up testing: [Timing and location]
  • HIV follow-up if nPEP started: [Plan]
  • Immunization follow-up: [Plan if HPV/HBV due]
• Mental Health Referrals: [Referrals provided; caregiver response]
• Return Precautions: [New/worsening bleeding, pain, dysuria, discharge, fever; self-harm concerns; escalating behavioral crisis; new safety threats]
• Pending Results Communication: [Safe contact method; expected timeline]
• Discharge Time: [Time]

Signatures

Examiner Signature / Credentials / Date / Time: [Signature block]

(If any section is not performed, include a brief rationale rather than omitting.)