1. Documentation

2. Documentation Important to have clear, concise, thorough documentation
Good documentation may eliminate need for court

3. Documentation cont’d
Any interaction between yourself & patient/family should document statements given and behaviours demonstrated
Include in the record
Name of person making statement/exhibiting behaviour
Date/time of statement/behaviour
Exact words of statement – where possible use quotation marks

4. Documentation cont’d Injuries Body injuries drawn on body diagram
use measurement scale and note size
note the colour
note the shape
colour photography (not polaroid)
Genital injuries drawn on genital diagram
description in appearance and location
use superimposed clock for location
acute vs. non-acute

5. Interpreting findings & coming to conclusions
Will be required for police & CAS
Be descriptive of what you see on the genital examination
Use classification scale

6. Interpretation cont.
Try not to state “The examination did not show evidence of sexual abuse”
Because examinations in sexual abuse are often normal or non-specific you should state “ the examination demonstrated normal or non-specific findings and therefore neither confirms nor denies the alleged concerns of sexual abuse”

7. Example
Jocelyn is 9 year old girl who was brought to the ER dept for an alleged sexual assault by her step father.
assault allegedly occurred last night. She was accompanied to the ER by her mother and police.
History was initially gathered from police and mother. The history revealed one episode of alleged fondling and attempted penetration. Mother reports that Jocelyn has not complained of vaginal pain, bleeding or discharge.

8. Example cont.
Further medical history was gathered from mother. The examination was explained to Jocelyn & mother. Jocelyn agreed to have the examination done as well as parts of the SAEK.
Physical examination of the head, neck, cardiovascular system and abdomen demonstrated no abnormalities. The breasts and pubic hair were Tanner stage 1. The patient was examined in the frog leg supine position. The external genitalia were normal. The hymen was crescentic in configuration with a normal rim and smooth edge. The anal examination was normal.

9. Example cont.
Impression statement: The genital findings are normal and therefore neither confirm nor deny the sexual abuse concerns. It must be remembered that the majority of physical examinations done in children and adolescents where sexual abuse concerns have arisen are normal or show non-specific findings.

10. Cont.
A normal examination does not rule out the possibility of sexual abuse as some forms of sexual abuse may not result in injuries detectable on examination and genital tissue heals quickly and often without residua.

11. Example –concerning/clear evidence
The genital examination revealed a hematoma on the left labia majora. Bruising and a small abrasion was noted in the posterior fourchette. The hymen was estrogenized, complete transections of the hymen were noted at the 4 & 7 o’clock positions. Bruising on the hymen was noted at the 6 o’clock position. Some bleeding was noted from the transected areas of the hymen. The anal exam was normal.

12. Interpretation of findings
The genital findings are clear evidence of a penetrating type injury and are consistent with the alleged sexual assault history provided by the patient.