The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach -- address acute complaints, gather pertinent historical data, describe findings, and document treatment and follow-up care; and (2) Ensuring the accuracy and objectivity of medical forensic reports by seeking education on proper report writing. (the U.S. Department of Justice, 2004) Photographic evidence of the injuries sustained by the patient may be used to supplement the medical forensic history and to document findings of a physical nature. The U.S. Department of Justice states that following recommendations in the area of photographic documentation: (1) Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, while others limit photography to detected injuries; (2) Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation as well as educated in forensic photography and in ways to maintain the patient's privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used; (3) Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses of photographs during investigation and prosecution, and the possible need for follow-up photographs; (4) Consider the patient's comfort and need for modesty. • Identify who will be present when photographs are taken; and (5) Take initial and follow-up photographs as appropriate, according to jurisdictional policy. VII. Evidence Collection Procedures

In relation to exam and evidence collection procedures, the U.S. Department of Justice states that jurisdictional policy is the guidelines that examiners look to in collecting evidence. Recommendations made for exam and evidence collection procedures include the following: (1) Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions; (2) Be aware of evidence that may be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested; (3) Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence; (4) Understand the implication of the presence or lack of semen (in cases involving male suspects); (5) Seek informed consent from patients for each portion of the exam and evidence collection; (6) Modify the exam and evidence collection to address the specific needs and concerns of patients; (7) Conduct the general physical and anogenital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient's consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence; (8) Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy; (9) Collect blood and/or urine for toxicology screening, if applicable; and (10) Keep medical specimens separate from forensic specimens collected during the exam. (U.S. Department of Justice, 2004)

VIII. Sexual Assault Facilitated Through Drug

The health care provider, whether it be a nurse or a medical doctor must give consideration to the possibility that the individual may have been drugged in order for the perpetrator to facilitate the assault. Recommendations stated by the U.S. Department of Justice includes education of all responders in this area as well as obtaining informed consent from patients when testing their urine. When the patient provides permission, urine samples should be immediately collected if ingestion of drugs for facilitation of the assault is suspected. If the ingestion of drugs for facilitation of sexual assault was within 24 hours of the exam a blood sample should be collected as well.

IX. STIS and STDS

Sexually transmitted disease or infection evaluation and care is addressed as well by the U.S. Department of Justice which include the following: (1) Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, follow-up care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended; (2) Consider testing patients for STIs during the initial exam on a case-by-case basis. If testing is done, follow the guidelines...

(Note, however, that treatment may not be appropriate for some individuals -- for example, if they have a condition that may be adversely affected by taking prophylaxis.) the CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and bacterial vaginosis (BV), as well as the hepatitis B virus. If accepted, provide care that meets or exceeds CDC guidelines. If declined, it is medically prudent to obtain cultures and arrange for a follow-up exam and testing. Seek informed consent from patients for treatment, according to facility policy; (4) Encourage and facilitate follow-up STI examinations, testing, immunizations, and treatment as directed; and (5) Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV / AIDS. Meet or exceed CDC recommendations. Discuss risks and benefits of the prophylaxis with patients prior to their decisions to accept or decline treatment. Careful monitoring and follow-up by a health care provider or agency experienced in HIV issues is required.
X. Informed Consent & Confidentiality Issues

Informed consent is necessary for the following: (1) general medical care; (2) pregnancy testing and care; (3) testing and prophylaxis for STIs; (4) HIV prophylaxis; (5) permission to recontact the patient for medical purposes; and (6) release of medical information. (U.S. Department of Justice, 2004) it is necessary as well to gain consent of the patient for the purpose of forensic exam and evidence collection. Informed consent for forensic examination in clued the following: (1) notification to law enforcement or other authority; (2) photographs including colposcopic images; (3) the examination itself and evidence collection; (5) toxicology screening; (5) release of information and evidence to law enforcement; (6) permission to recontact patients for reasons related to their criminal sexual assault case; and (7) Patient notification in case of DNA match or additional victims. (U.S. Department of Justice, 2004)

Another issue that must be addressed by health care personnel as well as nursing staff is the 'confidentiality' of patients. Recommendations of the U.S. Department of Justice in the area of patient confidentiality include: (1) make sure jurisdiction policies address confidentiality issues related to the exam process; (2) increase the understanding of responders and patients in relevant confidentiality issues; (3) consider the impact of the Federal privacy laws regarding health information on victims of sexual assault; and (5) strive to resolve intrajurisdicitonal conflicts. (U.S. Department of Justice, 2004)

The 'Sexual Assault Forensic Examiner' is many times a nurse. These nurses/examiners must be properly education and trained in this area and are required to be committed to providing health care of high quality and of compassion while conducted evidence collection in a manner that is thorough and appropriate. The 'Sexual Assault Nurse Examiner' (SANE) is a registered nurse who has received specialized education as well as fulfilling clinical requirements prior to conducting these examinations. Certification for SANEs are common for this endeavor in health care. The U.S. Department of Justice states that it is highly beneficial for the SANE to know: (1) the dynamics and impact of sexual victimization; (2) Jurisdictional laws related to sexual offenses; (3) Coordinated multidisciplinary response, roles of each responding agency, (4) procedures for communicating with each agency during immediate response; (5) the importance of examiner neutrality and objectivity during the examination; (6) the broad spectrum of potential evidence and physical findings in these cases; and (7) the importance of the medical forensic history and other documentation. (2004) it is important that the nurse understand the forensic significance of the examination procedure and evidence collection in sexual assault cases. The examination is a methodical documentation of physical findings and facilitation of evidence from patients' bodies and clothing. The evidence collected during the exam is used to reconstruct the details of the assault on the victim and enables this to be accomplished in a scientific and objective manner. The biological evidence which is gathered during the examination, specifically, semen, blood, vaginal secretions, saliva, vagina epithelial cells, and other biological evidence can be identified as well as genetically typed in the forensic crime lab. The information gathered provides evidence concerning the determination of sexual contact, the circumstances of the incident and may be compared to reference samples that are collected from the patient and suspects of the sexual assault.

XI. Forensic Medicine History

The forensic medical history which must be included in the report following a sexual assault includes the following information:

1)…