Step 13: Finalize Documentation
Complete documentation
Use Texas Attorney General approved SAEK forensic assessment documentation forms or facility-approved medical forensic assessment documentation forms.
- Pertinent medical and surgical history,
- Medications.
- Complete medical forensic assessment documentation.
- If more than one examiner completes the assessment, clearly document which examiner completed what portion of the history and examination.
- 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.
Seal the 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 if 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 if transferring evidence.
For more information on finalizing the documentation see the Protocol.
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