Medical Forensic Examination

Medical Forensic Examination

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Pediatric Assessment Flowsheet

Step-by-step guide through the forensic assessment

1. Informed consent

  1. Informed consent occurs throughout the examination process. Education regards reasons for procedures should be explained to increase physical and psychological safety.
  2. Introduce self to patient, describe plan of care, role of forensic health care professional and expected length of time to complete patient assessment. Invite patient to ask questions.
  3. Obtain consent from the patient following the prescribed methodology.
  4. All patients, regardless of age, can assent or decline any portion or all the medical forensic assessment. 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 can return at another time for medical forensic assessment. If patient returns within 120 hours since the assault, a SAEK may be collected. Inform patient and caregiver that the decision to decline or postpone the examination may result in additional medical costs.

2. Reporting

Sexual assault of children less than 18 years old must be reported to law enforcement and/or child protective services (see Mandatory Reporting).

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. History is obtained based on child’s age and developmental abilities. Use the child patient’s verbiage and use quotations if possible. Not all children will be able to answer all questions asked. 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:
    • To the best of your ability, obtain an accurate medical forensic history of the patient’s own statements, in quotations.      
    • All those present during the patient’s history and examination.
    • Time, date, and location of assault(s).
    • Contact and/or penetrative acts by suspect(s)
    • Was the suspect injured in any way, if known?
    • Use of lubricant, including saliva.
    • Patient’s actions between the sexual assault and arrival at the facility (brushing teeth, using mouthwash, smoking, vaping, changing clothes, vomiting, swimming, showering, or bathing).
    • Was a condom used?Did ejaculation occur? Where?
    • Any weapon use or physical force, or threat of weapon use or physical force?
    • 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 assent is obtained.
    2. Wear powder-free gloves when collecting and packing evidence. Change gloves often and between each swab collection. Open sealed SAEK. Consider wearing gloves when handling any kit contents. Inspect for integrity prior to using SAEK. Open sealed SAEK. Consider wearing gloves when handling any kit contents.
    3. Refrain from talking, coughing, or sneezing when handling evidence.
    4. Seal items of clothing separately in paper bags; only the patient’s underwear go in the SAEK.
    5. 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 unexplained by other causes).
      • 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 (NIJ, 2017).
      • Collect blood and/or urine from patient as per facility protocol.
      • Place blood and/or urine DFSA specimens in 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.
      • 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.
    6. All wet evidence (excluding swabs) should be air-dried prior to packaging whenever 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 specimens for drying. 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 with date and time of collection and the examiner’s initials.
  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 each 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 and unique identifier number, examiner’s initials, date, and time.
    3. 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.
    4. Chain-of-custody documentation must include:
      • Receipt,
      • Storage,
      • Transfer of evidence,
      • Date and time of each transfer, and
      • Printed name and signature of each person in possession of or transferring or receiving custody.
  5. Swab and evidence collection: Concentrating evidence on two swabs from each site is best practice (NIJ, 2017). Explain process to patient and guardians, and reason for collection before each site collection. Take digital images per facility protocol during assessment and evidence collection processes.
    1. Moisten swabs with sterile water, if necessary, directly 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 (change gloves between each sample collection, do not speak or cough while handling swabs).
    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 degrades 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.
      • Recommended process: Put on new gloves. Using two swabs, swab inside the patient’s mouth around the gum lines and under the tongue.
      • 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).
      • 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.
    5. Patient’s known DNA buccal swabs / 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, including children.
      • 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 laced with chemicals that stabilize nucleic acids for long-term storage. Follow facility protocol for use of FTA cards. These specimens do not require refrigeration.
      • Patient’s known blood sample: Patient’s known liquid blood samples (i.e., those in a blood tube) should not be collected as evidence. 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. 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) 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 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 helps 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 onto a paper bindle included in the SAEK (DoJ, 2013). After dried secretions have been scraped into 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. If patient lives with the assailant, touch DNA may have limited forensic value. “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. 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 and labia minora. Avoid the urinary meatus. Prevent contact of swabs with prepubertal female’s hymen. Contact with the hymen can cause extreme pain in prepubertal females. It may be necessary to pre-moisten the cotton- tipped applicators with sterile water. Patients may collect their vulva 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 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). 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.
    11. Vaginal swabs: Should never be collected in prepubertal females (have not reached menarche), except under sedation with physician direction and supervision, or by physician directly, only if sedation is medically indicated. Evidence collection is not a reason for sedation. Use trauma-informed care and clinical judgement.
    12. Penile swabs: Purpose is to recover foreign DNA.
      • 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.
    13. 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.
    14. 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.
    15. Any retained objects in vagina or rectum: Purpose of collection is to recover foreign DNA or evidence. The removal of retained objects in the vagina or rectum is a medically indicated process. Use trauma-informed care and clinical judgement.
      • Recommended process: Collection of retained objects in prepubertal females should be done under sedation by physician, protocol, or direct supervision. Collect retained object. Air dry. Once dry, place in additional evidence envelope. Label envelope with patient’s name, date, time, and examiner’s initials.
  6. Documentation: Use 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). 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).
    • Document patient’s:
      • Pertinent medical and surgical history, and
      • Medications.
    • When more than one examiner completes the assessment, clearly document which examiner completed what portion of the history and examination.
    • 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 in 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.
    • 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.
    • Complete appropriate chain-of-custody documentation when transferring.