Medical Forensic Examination

Medical Forensic Examination

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Adult/Adolescent Assessment Flowsheet

Step-by-step guide through the forensic assessment

1. Informed consent

  1. Introduce self to patient and describe plan of care, role of medical forensic health care professional and expected length of time to complete patient assessment. Invite patient to ask questions.
  2. Obtain consent from the patient following the prescribed methodology.
  3. All patients, regardless of age, can assent or decline any portion or all the medical forensic assessment. Reinforce patients have rights. Examiners should be flexible and alter process and approach as patient assents or declines throughout the examination. If the patient continues to decline, the patient may return at another time for medical forensic assessment. If patient returns within 120 hours (some jurisdictions may collect evidence more than 120 hours) since the assault, a SAEK may be collected. Inform patient that this may result in additional medical costs.

2. Reporting

Determine if patient (18 years old and older) wishes to report to law enforcement (see reporting options)

3. Medical Assessment

The medical assessment may take place before or concurrently with forensic sexual assault assessment, depending on facility policy.

  1. Obtain an accurate history of the incident(s). Health care professionals are neutral receivers of the information. In criminal cases, the defense has a right to learn of any inconsistent statements, statements that deny that a sexual assault occurred or other statements that may be important to the defense, regardless of whether the examiner believes those statements are true. Brady v. Maryland, 373 U.S. 83 (1963); Texas Code of Criminal Procedure §39.14(h).
  2. Additionally, document:
    1. To the best of your ability, obtain an accurate medical forensic history of the patient’s own statements, in quotations.
    2. All those present during the patient’s history and assessment.
    3. Time, date, and location of assault(s).
    4. Contact and/or penetrative acts by suspect(s)
    5. Was the suspect injured in any way, if known?
    6. Use of lubricant, including saliva.
    7. Patient’s actions between the sexual assault and arrival at the facility (i.e., including but not limited to, brushing teeth, using mouthwash, changing clothes, vomiting, smoking, vaping, swimming, douching, showering, or bathing).
    8. For adults or adolescents, “Have you had sexual contact within the last five days?”Use best clinical judgment. Transparency is important; explain the reasons behind asking these questions, such as impact on overall health and evidence collection.
    9. Was the patient or suspect menstruating at time of the assault(s) or at the time of the examination? Was the patient wearing a menstrual cup during the sexual assault or at the time of the sexual assault medical forensic assessment?
    10. Was a tampon present during the incident or at the time of medical forensic assessment?
    11. Was a condom used?
    12. If known, was there patient or suspect ejaculation? Where?
    13. Any weapon use or physical force, or threat of weapon use or physical force?
    14. Description of condition of clothing (and was clothing torn or stained prior to assault?).
  3. Evidence collection and packaging:
    1. Ensure written consent or authorization is obtained prior to assessment and evidence collection. Ensure assessment and evidence collection processes are culturally sensitive and patient centered. Ensure ongoing patient assent is obtained. Wear powder-free gloves when collecting and packing evidence. Change gloves often and between each item of potential evidentiary value. Inspect for SAEK integrity prior to using SAEK. Open sealed SAEK. Consider wearing gloves when handling any kit contents.
    2. Refrain from coughing or sneezing when handling evidence.
    3. Seal items of clothing separately in paper bags; only the patient’s underwear go in the SAEK.
    4. Use a prepackaged DFSA specimen kit to collect urine specimens, if indicated (i.e.,including but not limited to, gaps in memory, loss of consciousness, nausea, vomiting, dizziness that are unexplained by other causes).
      1. Drug facilitated sexual assault (DFSA) or toxicology collection kit. DFSA urine is recommended to be frozen, or at least refrigerated, and documentation of chain of custody must be maintained (National Institute of Justice [NIJ], 2017).
      2. Collect blood and/or urine from patient as per facility protocol.
      3. Place sealed and labeled blood and/or sealed and labeled urine DFSA specimens in the provided biohazard bag that is sealed and labeled. Place urine DFSA specimen inside a cardboard box which is also sealed and labeled. Urine should never be placed in the SAEK. Maintain chain of custody of the DFSA specimens.
      4. If facility does not have prepackaged DFSA kits, examiner may collect one grey-top tube of blood and a dirty urine specimen (do not have patient wipe before specimen collection). Maintain chain of custody of specimens. Follow facility policies.
    5. All wet evidence (excluding swabs) should be air-dried prior to packaging wherever possible. Swabs can be placed directly in swab boxes and do not require additional air drying. If air drying is not possible, wet evidence should be refrigerated as soon as possible. Consider contacting law enforcement who has jurisdiction to take custody of specimens for drying.
    6. Seal envelopes containing evidence with self-adhesive labels and/or tape. The examiner should never use saliva to seal envelopes.
    7. Seal and label all evidence collected and place date and time of collection and the examiner’s initials on packaging.
  4. Chain of custody:
    1. Collect evidence so that it will be admissible as evidence in legal proceedings later. Therefore, chain of custody must be maintained and documented throughout the entire patient assessment and evidence collection processes. Chain of custody documents the dates and times of everyone who handles every piece of evidence, from the time it is collected through to legal proceedings. 
    2. Evidence should be labeled with patient’s name, date of birth, unique identifier number, examiner’s initials, date, and time.
      1. If adult patient chooses non-reporting method, the external SAEK is labeled only with the unique identifier number (often the medical record number or the Track-Kit barcode). The Track-Kit identifier can be utilized.
      2. Consider also labeling additional evidence not included in the kit (i.e., clothing collected when patient is reporting to law enforcement) with Track-Kit labels without the barcode.
      3. Evidence inside the SAEK is labeled according to standard facility procedure. Follow facility protocols on non-reporting evidence collection.
      4. Consider providing a card with the unique identifier for the patient if the Track-Kit identifier is not utilized.
    3. Chain-of-custody documentation must include:
      1. Receipt,
      2. Storage,
      3. Transfer of evidence,
      4. Date and time of each transfer, and
      5. Printed name and signature of each person in possession of and transferring or receiving custody.
  5. Swab and evidence collection: Concentrating evidence on two swabs from each site is best practice (NIJ, 2017). Explain process and reason for collection to patient before each site collection. Take digital images per facility protocol during assessment and evidence collection processes.
    1. Moisten swabs with sterile water, if necessary, immediately prior to evidence collection. Swabs can be placed directly in the swab box without the need to air dry swab samples.
    2. Maintain strict practices to prevent cross-contamination of evidence (i.e., change gloves between each site collection, do not speak, cough, or sneeze while handling the swabs). Use caution to avoid examiner contamination of evidence. Each sample should be placed in the appropriate evidence box prior to starting another sample collection to avoid contamination.
    3. Seal swabs from left and right body parts in the same envelope but in different boxes (i.e., swabs from left and right breasts should be placed in different boxes, but both boxes can be sealed inside one envelope). Label swab boxes using labels in SAEK with site swabbed and if blind swab. Consider self-collected swab collection with guidance from health care professional as the process is trauma-informed and patient centered.
    4. Oral swabs: Purpose is to recover foreign DNA. Foreign DNA is diluted or removed quickly in the mouth. If known or suspected oral assault, collect oral swabs as soon as possible, and before patient eats or drinks. When patient describes oral penetration or contact, it is suspected, or patient is unconscious, collect oral swabs. If oral assault occurred, collect oral swabs for foreign DNA first. Wait 15–20 minutes. Patient may also swish mouth with water then wait 15–20 minutes. Patient’s known DNA buccal swabs or an FTA® card should be obtained from every patient. Check local protocols. Some forensic programs may collect known DNA buccal swabs and an FTA® card.
      • Recommended process: Put on new gloves. Using two swabs, swab inside the patient’s mouth around the gum lines, and under the tongue. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the oral swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
      • Patients may collect their oral swabs with guidance from health care professional as the process is trauma-informed and patient-centered care. For chain-of-custody purposes, patients must be observed by the examiner while collecting their own oral swabs. Document self-swabbing.
      • Prior to collecting swabs from an unresponsive or unconscious patient, it is recommended to consult facility’s risk manager or legal personnel (DoJ, 2013).
    5. Patient’s known DNA buccal swabs and/or Whatman® Flinders Technology (FTA®) card: Purpose is to determine patient’s DNA for comparison to other samples. If oral assault occurred, collect oral swabs for foreign DNA first (see “Oral swabs” step above). Wait 15–20 minutes. Patient may also swish mouth with water then wait 15–20 minutes. Patient’s known DNA buccal swabs or an FTA® card should be obtained from every patient. Check local protocols. Some forensic programs may collect known DNA buccal swabs and an FTA® card.
      • Recommended process: Put on new gloves. Using two swabs, swab the inner cheeks of the patient’s mouth. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the patient’s known DNA envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
      • Some facilities use FTA® blood cards in lieu of patient’s known DNA buccal swabs. FTA® cards are filter papers impregnated with chemicals that stabilize nucleic acids and enable long-term storage. Follow facility protocol for use of FTA® cards. These specimens do not require refrigeration.
      • Patient’s known liquid blood sample: Patient’s known liquid blood samples (i.e., those in a blood tube) should not be collected as evidence for the SAEK. SAEKs with blood samples must be refrigerated. Most facilities and crime labs do not have the refrigerated storage space necessary to correctly store these samples.
    6. Patient’s head hair combings and comb, or swabs: Purpose is to collect trace evidence, including foreign hairs in cases of unknown or acquaintance sexual assault. Swabs of matted hair may be collected in lieu of combing. Examiner may choose to swab matted hair in lieu of combing hair. Using two swabs pre-moistened with sterile water, swab matted hair or areas where patient states may yield foreign DNA. Use trauma-informed care and clinical judgement.
      • Recommended process: Put on new gloves. Open a small paper included in the SAEK over the patient’s lap. Using a comb provided in the SAEK, comb the patient’s hair over the paper. If patient prefers, the patient may choose to comb their own hair, in the presence of the examiner. Document self-collection. Bindle the comb into the paper and place in the envelope. Bindling is the process of folding paper into thirds lengthwise, then into thirds widthwise, and finally pocketing edges to prevent content slippage. Label and seal with examiner’s initials. Place envelope in the SAEK. If patient has hair extensions and consents to collection, collect samples of hair extensions as evidence and notate the presence of hair extensions. If patient is aware, also notate if extensions are synthetic or human hair.
    7. Clothing: Purpose is to recover possible foreign matter or DNA, and to note any damage to clothing. Foreign matter or DNA may be deposited on the patient’s clothing during a sexual assault. Damaged or stained clothing may be evidence. Consider photographing damaged or stained clothing. Follow facility policies. When taking pictures adhere to the guidelines established on the photographs page.
        • Underwear: Regardless if the patient changed underwear (panties or other undergarments close to patients’ genitalia; does not include bras) after the sexual assault, the examiner should always collect underwear if the patient consents. Body fluids may be transferred to the underwear. If the patient is not wearing underwear at the time of the assessment, collect clothing that was in direct contact with the patient’s anogenital area or thighs. Underwear is to be placed in the SAEK, if there is space.
        • Outer clothing: Clothing worn during the sexual assault or immediately afterward may have foreign DNA and other materials and should be collected. Typical clothing collected includes bra, pants and shirts. Coats, socks and shoes may not need to be collected. Collection is based on the patient’s description of the sexual assault and the examiner’s clinical judgment. Clothing does not go in the SAEK (except underwear).
      • Clothing collection process:
      • Put on new gloves. Place a clean sheet on the floor. Take the large changing paper out of the SAEK and spread it out on top of the clean sheet. Have the patient stand in the middle of the changing paper. Provide the patient some privacy when removing clothing (i.e., hold up a gown). Have the patient place individual items in separate areas on the changing paper.
      • Label the changing paper. Inspect each piece of clothing. Document item, color, and any damage on the forensic record. Label each item of clothing with patient’s name, date seen and examiner’s initials. Consider photographing damaged or stained clothing.
      • Place each item of clothing in a separate paper bag. Clothing does not go in the SAEK. Dry wet clothing, if possible. If unable to dry wet clothing, arrange for release to law enforcement with chain of custody. Notify law enforcement that the clothing is wet, so drying arrangements can be made. Bag each item individually to prevent cross-contamination. Seal and label each bag with date, time and examiner’s initials. Seal all clothing bags inside a large bag. Seal and label large bag with date, time and examiner’s initials.
      • Label each large bag with a number also. For example, if there is a SAEK plus one bag of clothing, label SAEK “1 of 2” and bag “2 of 2”. This documentation helps to ensure all evidence stays together during evidence transfers.
    8. Dried secretions/debris: Purpose is to collect any dried secretions or debris found on the patient.
      • Recommended process: Put on new gloves. Inspect patient from head to toe. Using dried secretions/debris envelope, collect any suspected foreign material. Note on envelope description of the material.
        • Debris: Bindle debris into a paper provided in the SAEK and place in the envelope. Label with site of collection and possible sample information and seal with examiner’s initials. Place envelope in the SAEK.
        • Dried secretions: Flake dried secretions by gently scraping the secretions with a dry swab onto a paper bindle included in the SAEK (DoJ, 2013). After dried secretions have been scraped into the bindle, moisten two swabs with sterile water. Swab site with two moistened swabs. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the dried secretions/debris envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
        • Touch DNA: Purpose is to collect any foreign DNA on patient, based on description of assault, patient actions between the assault and the exam and/or assessment findings (i.e., if patient describes being strangled, there may be foreign DNA on the patient’s neck).
        • Recommended process: Wear gloves while completing head-to-toe patient assessment. Swab any sites patient states there may be foreign DNA. “Use two lightly moistened swabs, from each affected area” (NIJ, 2017). Using patient’s own words, document site and source on SAEK envelope, swab box and medical forensic record. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in one of the dried secretions/debris envelopes. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    9. Fingernail swabs: Purpose is to collect foreign DNA, based on description of assault, patient’s actions during and after the assault, and the exam and/or assessment findings.
      • Recommended process: Put on new gloves. Moisten the two small swabs and swab under the patient’s fingernails, one set of two swabs for left hand nails and one set of two swabs for right hand nails. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the fingernail swabs envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    10. Patient’s pubic hair combings and comb, or swabs: Purpose is to collect trace evidence, including foreign hairs in cases of unknown or acquaintance sexual assault. Swabs of matted hair may be collected in lieu of combing. Examiner may choose to swab matted hair in lieu of combing hair. Using two swabs pre-moistened with sterile water, swab matted hair or areas where patient states may yield foreign DNA. Use trauma-informed care and clinical judgement.
      • Recommended process: Put on new gloves. Open a small paper included in the SAEK under the patient’s buttocks. Using a comb provided in the SAEK, comb the patient’s hair over the paper. If patient prefers, the patient may choose to comb their own hair, in the presence of the examiner. Document self-collection. Bindle the comb into the paper and place in the envelope. Bindling is the process of folding paper into thirds lengthwise. Examiner may choose to swab matted hair in lieu of combing hair. Using two swabs pre-moistened with sterile water, swab matted hair or areas where patient states may yield foreign DNA.
    11. Vulva swabs: Purpose is to recover foreign DNA.
      • Recommended process: Put on new gloves. Swab the vulva with two swabs total (simultaneously). Swab the inner labia majora, labia minora and hymen. Avoid the urinary meatus. It may be necessary to pre-moisten the cotton-tipped applicators with sterile water.
      • Patients may collect theirㅤvulva swabs with guidance from health care professional as the process is trauma-informed and patient-centered care. For chain-of-custody purposes, patients must be observed by the examiner while collecting their ownㅤvulva swabs. Document self-swabbing.
      • Prior to collecting swabs from an unresponsive or unconscious patient, it is recommended to consult facility’s risk manager or legal personnel (DoJ, 2013).
      • Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the vulva/scrotal swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    12. Vaginal/cervical swabs: Purpose is to recover foreign DNA. Vaginal and cervical swabs should be collected only on adolescents or adults. The use of vaginal washings is not recommended as it dilutes the sample. For  patients who do not consent to speculum insertion for examination and evidentiary purposes, consider offering:
        • Blind vaginal swab collection by examiner,
        • Blind self-collected vaginal swabs while examiner observes.
      • For chain-of-custody purposes, patients must be observed by the examiner while collecting their own vulva swabs. Document self-swabbing.
      • Prior to collecting swabs from an unresponsive or unconscious patient, it is recommended to consult facility’s risk manager or legal personnel (DoJ, 2013).
      • Speculum lubrication: There is little literature condoning or refuting the use of a water-based gel lubricant to facilitate speculum insertion (Bakker, et al., 2017). Therefore, for patient comfort, a scant amount of water-based gel lubricant may be utilized if applied to outside of speculum bills.
      • Recommended process: Change gloves. Insert vaginal speculum. Gently place two swabs slightly in the cervical os, hold for 5–10 seconds, swab the surface of the cervix, then swab the posterior fornix (bottom of cervix and the space below the cervix) of the vagina (Speck & Ballantyne, 2015). Remove speculum. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the vaginal/cervical/penile swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    13. Penile swabs: Purpose is to recover foreign DNA. Consider allowing patients to swab their own penis.
      • Recommended process: Change gloves. Pre-moisten two swabs and swab the head of the penis, staying away from the urethral meatus. Use same two swabs to swab under the foreskin and the shaft of the penis.
      • Patients may collect their penile swabs with guidance from health care professional as the process is trauma-informed and patient-centered care. For chain-of-custody purposes, patients must be observed by the examiner while collecting their own penile swabs. Document self-swabbing.
      • Prior to collecting swabs from an unresponsive or unconscious patient, it is recommended to consult facility’s risk manager or legal personnel (DoJ, 2013).
      • Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the vaginal/cervical/penile swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    14. Scrotal swabs: Purpose is to recover foreign DNA. Consider allowing patients to swab their own scrotum.
      • Recommended process: Change gloves. Pre-moisten two swabs. Use two swabs to swab the scrotum.
      • Patients may collect their scrotal swabs with guidance from health care professional as the process is trauma-informed and patient-centered care. For chain-of-custody purposes, patients must be observed by the examiner while collecting their own scrotal swabs. Document self-swabbing
      • Prior to collecting swabs from an unresponsive or unconscious patient, it is recommended to consult facility’s risk manager or legal personnel (DoJ, 2013).
      • Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the vulva/scrotal swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    15. Anal swabs: Purpose is to recover foreign DNA.
      • Recommended process: Change gloves. Pre-moisten two cotton-tipped applicators. Use two swabs to swab around the external anus. Place the two swabs into a swab box. Close both ends of the box. Label box. Place labeled box in the anal swab envelope. Label and seal the envelope with examiner’s initials. Place envelope in the SAEK.
    16. Any retained objects in vagina or rectum: Purpose of collection is to recover foreign DNA or evidence. Follow facility protocols for safe removal of any retained objects in vagina or rectum. Use trauma-informed care and clinical judgement.
      • Recommended process: Collect tampon, menstrual cup or retained object. Air dry, if possible. Once dry, place in dried secretions/debris envelope. Label and seal envelope with examiner’s initials. Place envelope in the SAEK.
  6. Documentation: Use Texas Attorney General approved SAEK forensic assessment documentation forms or facility-approved medical forensic assessment documentation forms. Document an accurate history of the incident(s). Health care professionals are neutral receivers of the information.Use terms such as “reported” or “stated” rather than “alleged” when documenting patient’s history (CCP §56A.2505). Document use of interpreter, if applicable. Follow facility protocol for electronic or written documentation. Print or write legibly. Accurately document all patients’ statements (DoJ, 2013).
    1. Document patient’s:
      • Pertinent medical and surgical history,
      • Last menstrual period,
      • Gravida and para, and
      • Medications.
    2. Complete medical forensic assessment documentation. Place one copy of forensic documentation in SAEK. Ensure there is a copy of the documentation for law enforcement. Original copy stays at the facility.
  7. Sealing SAEK: Change gloves. Remove red evidence labels and small bright orange biohazard label from SAEK. Once all evidence is appropriately labeled and sealed, seal SAEK with red evidence tape provided in the kit. Double check if sealed and re-seal kit when needed. Document if opened and resealed. Add biohazard label to front of SAEK. Complete documentation on the front of the SAEK.
    1. Sign, date, and time over the evidence tape so signature goes from kit across label back to kit. This allows examiner to verify that tampering did not occur while testifying in legal proceedings.
    2. Complete appropriate chain-of-custody documentation when transferring evidence.