Complete documentation

Use Texas Attorney General approved SAEK forensic assessment documentation forms or facility-approved medical forensic assessment documentation forms.

1. Document the patient’s
   • Pertinent medical and surgical history
   • Medications
2. If more than one examiner completed the assessment, clearly document which examiner completed what portion of the history and examination.
3. 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

Seal the SAEK

1. Change gloves
2. Remove red evidence labels and small bright orange biohazard label from SAEK
3. Once all evidence is appropriately labeled and sealed, seal SAEK with red evidence tape provided in the kit
4. Double check if sealed and re-seal kit if needed
5. Document if opened and resealed
6. Add biohazard label to front of SAEK
7. 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
   • Complete appropriate chain-of-custody documentation if transferring evidence

For more information on finalizing the documentation see the Protocol.