Sexual Assault Medical-Forensic Exam Note (Adult/Adolescent)

Encounter Information

(Use trauma-informed, nonjudgmental language throughout. Clearly distinguish patient-reported history from clinician observations. Avoid adjudicative terms like "alleged" or "claims." Use absolute dates/times when known; if unknown, state "approximate" and source. For missing information, document "Unknown," "Patient unsure," "Patient declined," or "Not assessed [reason]." Document consent or refusal for each component separately.)

• Date/Time of Arrival: [Date and time]
• Exam Start Time: [Time]
• Exam End Time: [Time]
• Location: [Facility name and department]
• Examiner Name and Credentials: [Name, credentials, SANE/SAFE certification if applicable]
• Chaperone: [Name and role / Not present (reason)]
• Interpreter: [Language, modality, interpreter ID / Not used] (Family members should not serve as interpreters.)
• Advocate Present: [Offered and accepted / Offered and declined / Not available] [Name and agency if present]
• Law Enforcement Present: [Yes, not in exam room / Yes, in exam room with patient permission / No / Not applicable]
• Evidence Kit Type and Jurisdiction: [Kit type, jurisdiction, kit ID / Not applicable]

Chief Complaint

[Patient-stated reason for visit; may include brief direct quote.] [Purpose: medical care only / medical plus evidence collection / non-report or anonymous kit option / undecided.]

Immediate Safety and Triage

[Brief status of urgent injuries, stabilization steps, pain control, acute bleeding, head injury concerns, abdominal pain, suicide/self-harm screen result and actions, immediate safety from assailant, intoxication/withdrawal risk, capacity concerns.] (If no acute issues: "No acute medical instability identified." If stabilization occurred, document succinctly and cross-reference details in later sections.)

Confidentiality and Reporting Status

• Limits of Confidentiality Explained: [Yes / No]; patient verbalized understanding: [Yes / No]
• Patient Preference for Law Enforcement Contact: [Yes / No / Undecided]
• Report Already Made: [Yes / No / Unknown]; [by whom; date/time if known]
• Mandatory Reporting Triggered: [Yes / No]; [reason: minor / vulnerable adult / firearm injury / other per local law]; [who notified, date/time, reference number]

(Do not document legal conclusions about whether a crime occurred.)

Consent

(Document consent/refusal separately for each component. Note that each procedure was offered and explained, questions answered, and patient may pause or stop at any time. If declined, document that risks/impact were discussed.)

• Decision-Making Capacity: [Intact / Impaired (describe factors) / Fluctuating] (If impaired, document rationale, accommodations, and legal/ethical framework used.)
• Consent Framework (Adolescents): [Consent/assent per local law; parent/guardian involvement status; legal authority documented] (Include only for adolescent patients.)
• Medical evaluation and treatment: [Consented / Declined / Deferred]
• Anogenital examination: [Consented / Declined / Deferred]; Speculum exam: [Consented / Declined / Not applicable]
• Forensic evidence collection: [Full kit / Partial kit / Specific elements only / Declined / Deferred] [Elements agreed to if partial]
• Photography—body surface: [Consented / Declined / Deferred]
• Photography—anogenital: [Consented / Declined / Deferred]
• Toxicology (medical): [Consented / Declined / Deferred]
• Toxicology (forensic): [Consented / Declined / Deferred]; Chain-of-custody maintained: [Yes / No]
• Release of information/evidence: [Recipient(s): law enforcement / advocacy / other]; [Consented / Declined]

History

History Source and Limitations

[Historian: patient / EMS / advocate / chart / other.] [Limitations: distress / dissociation / intoxication / memory gaps / language barrier / none.] (Document history as reported; do not conduct investigative interviews.)

Assault History (As Reported)

[Brief patient narrative summarizing what happened, using patient's words when possible, without adjudicative language.]

• Timing: [Date/time of assault; single vs repeated events; time elapsed since most recent event]
• Location: [Indoor / outdoor; setting; potential contamination risks]
• Assailant(s): [Number]; [Relationship: stranger / acquaintance / intimate partner / family / unknown] (Avoid speculative identity.)
• Acts and Exposures (as reported):
  • Oral contact: [to patient / from patient / both / none / unknown]; penetration: [Yes / No / Unknown]; by [description]
  • Genital contact/penetration: [vaginal / front genital]; by [penis / digit / object / unknown]
  • Anal contact/penetration: [Yes / No / Unknown]; by [description]
  • Digital penetration: [Yes / No / Unknown]; sites: [description]
  • Object penetration: [Yes / No / Unknown]; sites: [description]
  • Ejaculation: [Yes / No / Unknown]; location(s): [description]
  • Condom use: [Yes / No / Unknown]; breakage/slippage: [Yes / No / Unknown]
  • Lubricant/substance use: [Yes / No / Unknown]; [type/color/odor if known]
  • Physical violence/restraints/weapons: [description]; threats: [Yes / No / Unknown]; bites: [location(s)]
  • Strangulation/suffocation: [Yes / No / Unknown] (If yes, complete Strangulation sections below.)
• Substance involvement: Voluntary use: [type/amount/timing / none]; Suspected drug-facilitated assault: [Yes / No / Unknown]; Amnesia or unexpected sedation: [Yes / No]; Last ingestion time: [time if known]

Post-Assault Activities

[Activities potentially affecting evidence with approximate times: bathing/showering, douching, oral hygiene, urination/defecation, vomiting, eating/drinking/smoking, clothing change/laundering, wiping/cleaning skin, tampon/pad use, consensual sexual activity after assault, availability and location of clothing from assault.]

Relevant Medical History

• Allergies: [Allergies / NKDA]
• Current Medications: [Medications] (Note anticoagulants and immunosuppressants.)
• Significant PMH: [Bleeding disorders, HIV, chronic hepatitis, renal/hepatic disease, other / None]
• Relevant Immunizations: Hepatitis B: [status/date]; Tetanus: [status/date]
• Prior Surgeries Affecting Anatomy: [Urologic/gynecologic, gender-affirming, other / None]

Gynecologic/Urologic History

(Include as applicable.)

• LMP: [Date / Unknown / IUD-induced amenorrhea / Not applicable]
• Pregnancy Status: [Pregnant / Not pregnant / Unknown]; pregnancy test: [offered/accepted/declined]
• Current Contraception: [Method / None / Unknown]
• Lactation Status: [Yes / No / Not applicable]
• Baseline Genital/Urinary Symptoms Prior to Assault: [None / Description]

Strangulation/Suffocation History

(Include only if neck compression, choking, smothering, or hanging reported.)

• Loss of consciousness or near-syncope: [Yes / No / Unknown]; duration: [description]
• Voice changes/hoarseness: [Yes / No]
• Dysphagia/odynophagia: [Yes / No]
• Dyspnea/cough: [Yes / No]
• Neck pain/tenderness: [Yes / No]
• Headache/visual changes: [Yes / No]
• Petechiae: [Yes / No / Unknown]; locations: [description]
• Incontinence: [Urine / Stool / Both / No]
• Neurologic symptoms: [Confusion / Weakness / Paresthesias / Other / None]
• Time course since event: [description]

Review of Systems (Focused)

• Genital: [Pain / Bleeding / Dysuria / None]
• Rectal: [Pain / Bleeding / None]
• Oral/jaw: [Pain / Injury / None]
• Abdominal/pelvic: [Pain / None]
• Head/neck: [Symptoms including strangulation-related if applicable / None]
• Mental health: [Panic / Dissociation / Flashbacks / Other / None]

Physical Examination

Vital Signs and General Appearance

[Vital signs.] [Appearance and behavior: distressed / calm / tearful / withdrawn / cooperative.] [Orientation and mental status.]

Head-to-Toe Examination

(For each finding, document precise location, size in metric units, shape, color, pattern, tenderness, and swelling. Reference body maps/diagrams as applicable. Distinguish injury vs normal variant vs nonspecific finding. Document limitations: lighting, patient tolerance, timing since assault.)

• Head/Scalp/Face: [Findings / No visible acute injury noted]
• Eyes: [Findings including petechiae assessment / No visible acute injury noted]
• Mouth/Oropharynx: [Findings / No visible acute injury noted]
• Neck: [Findings / No visible acute injury noted]
• Chest/Abdomen/Back: [Findings / No visible acute injury noted]
• Extremities: [Findings / No visible acute injury noted]
• Skin Survey: [Findings / No visible acute injury noted]
• Exam Limitations: [Lighting / Patient tolerance / Timing since event / Other / None]

Anogenital Examination

(Include only if consented. Describe morphology and measurements without causal conclusions. Use clock-face positions and distances from landmarks. Note which sites were swabbed for evidence.)

[Exam positions used; visualization aids: speculum / colposcope / toluidine dye / none; patient tolerance; relevant anatomic considerations.]

• External Genitalia/Vulva or Scrotum: [Findings]
• Perineum: [Findings]
• Vagina/Cervix: [Findings / Not examined]
• Anus/Perianal Area: [Findings]
• Sites Swabbed for Evidence: [List / None]

Strangulation-Focused Examination

(Include only if strangulation reported or suspected.)

• Neck inspection: [Bruising / Abrasions / Erythema / None]; location and size: [description]
• Neck palpation: [Tenderness / Crepitus / Swelling / None]
• Voice quality: [Normal / Hoarse / Raspy / Other]
• Swallowing: [Normal / Painful / Difficulty / Not assessed]
• Respiratory status: [Normal / Abnormal: description]
• Focused neurologic exam: [Findings]
• Eye/oral petechiae: [Present: location / Absent]

Photography Documentation

(Include only if photographs taken.)

• Consent Documented: Body surface: [Yes / No]; Anogenital: [Yes / No]
• Camera System and Storage: [Description of system and secure storage method]
• Regions and Injuries Photographed: [Description]
• Orientation and Scale Images: [Mid-range and close-up with and without scale obtained / Partial / Not obtained]

(If photographs not taken, document reason: declined / equipment failure / no findings / patient preference / other.)

Evidence Collection

Evidence Collection Summary

• Kit Identifier: [Number, jurisdiction, kit type / Not applicable]
• Time Since Assault: [Duration]; within evidence collection window: [Yes / No / Borderline]
• Patient Choice: [Full kit / Partial kit / Medical only]

(For each element below, document: collected [Yes / No], time, collector, reason if not collected.)

• Clothing: [Items collected]
• Underwear: [Collected / Not collected]
• External Body Swabs: [Sites and collection status]
• Oral Swabs: [Collected / Not collected]
• Genital Swabs: [Sites and collection status]
• Anal/Perianal Swabs: [Collected / Not collected]
• Fingernail Swabs/Scrapings: [Collected / Not collected]
• Hair Combings/Debris: [Collected / Not collected]
• Reference Buccal Swab: [Collected / Not collected]
• Sanitary Products: [Collected / Not collected / Not applicable]
• Foreign Material: [Description and collection status / None recovered]

Toxicology

• Medical Toxicology: Specimen: [Urine / Blood / Other / Not collected]; collection time: [time]; results: [if available]
• Forensic Toxicology: Specimen: [Urine / Blood / Other / Not collected]; collection time: [time]; relation to suspected ingestion: [description]; chain-of-custody: [Maintained / Not maintained]; destination: [agency/lab]

Chain of Custody

(Mandatory when any evidence collected.)

• Evidence Sealed: [Yes / No]; seal numbers: [numbers if used]
• Date/Time Secured: [Date/time]; storage location: [location]
• Released To: [Name, agency, badge/ID, date/time / Not yet released]
• Incidents/Deviations: [Description and corrective actions / None]

Diagnostic Testing

• Tests Collected Today: [Pregnancy test, NAAT by site (GC/CT, trichomonas), baseline serologies (HIV, syphilis, hepatitis), UA, CMP, CBC, imaging as indicated]
• Results Available Today: [Results]
• Pending Tests: [Tests]; expected timeline: [timeframe]; responsible clinician: [name/service]
• Tests Not Performed: [Tests and rationale]
• Results Communication Plan: [How and by whom patient will be notified]

Treatments Provided

(Document what was offered and patient decision. If declined, note patient may return within relevant time windows, particularly for HIV nPEP and emergency contraception.)

• Wound Care/Pain Control: [Interventions provided / None indicated]
• STI Prophylaxis: [Offered/accepted/declined]; agents, doses, routes, times: [description]
• Hepatitis B Vaccination/HBIG: [Indicated/not indicated]; prior status: [description]; [administered/declined]
• HPV Vaccination: [Eligible/not eligible]; [administered/declined/deferred]
• HIV nPEP: Risk assessment discussed: [Yes]; time since exposure: [hours]; regimen: [description]; first dose: [date/time]; supply: [starter pack / 28-day]; baseline labs: [obtained/pending]; follow-up: [arrangement] / [Offered and declined] / [Not indicated (reason)]
• Emergency Contraception: [Options discussed]; method: [provided/prescribed/declined/not indicated]; timing: [description]
• Tetanus: [Indicated/not indicated]; [administered/declined]
• Referrals: [Advocacy, counseling, primary care, OB/GYN, infectious disease, other]

Assessment

(Problem list ordered by clinical urgency. Do not include statements declaring whether assault occurred or legal conclusions regarding consent.)

• Sexual assault — medical-forensic evaluation performed
• [Acute injuries by location and severity / No acute injuries observed]
• [Strangulation concern] (Include only if applicable.)
• [Pregnancy risk assessment]
• [STI exposure risk]
• [HIV exposure risk; nPEP status: initiated / declined / not indicated]
• [Acute stress reaction or mental health concerns] (Include only if clinically observed.)

(Normal examination findings are common and do not confirm or exclude assault.)

Discharge and Follow-Up

• Condition at Discharge: [Stable / Improved / Unchanged / Other]
• Safe Discharge Destination Confirmed: [Yes / No / Plan in progress]; [transportation and safety details]
• Advocacy Resources: [Offered; accepted/declined; referrals provided]
• Safety Planning: [Immediate danger assessment; safety plan elements; shelter/resources provided]
• Return Precautions: [Bleeding, increasing pain, fever, neurologic symptoms, dyspnea/voice changes if strangulation, suicidality, other]
• Follow-Up Appointments: [Provider/service, location, timeframe]
• Follow-Up Testing Schedule: [STI/HIV/syphilis/hepatitis testing intervals as indicated]
• Medication Instructions: [Adherence, side effects, interactions, missed dose guidance]
• Results Communication Plan: [Preferred contact method; confidentiality considerations; alternative contact]

(If patient is admitted, convert this section to an inpatient plan with handoff details.)