Medical Forensic Assessment Documentation

Some facilities use paper documentation while others use electronic medical record documentation or a hybrid of written and electronic documentation. In all patient interactions, it is important to maintain confidentiality of patient medical forensic assessment documentation according to HIPAA.
In addition to the standard privacy protections, sexual assault medical forensic assessment records contain sensitive information that have potential for use in criminal and/or civil investigations and prosecution.
As with all medical records, access to medical forensic assessment records must be limited to authorized parties for treatment and payment purposes and to those for whom patients have provided specific written consent or as required by law (see HHS Individual Rights under HIPAA).
“Documentation in the medical forensic record is critical not only for victim care in the aftermath of sexual assault but also in the investigation of the crime and processing of any evidence collected during the exam” (DoJ, 2017, p. 28). Educate patients regarding benefits and risks of assenting or declining examination and evidence collection options. 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)).
Health care professionals who collect sexual assault evidence samples “should record an inventory of each item as part of the medical forensic documentation” (DoJ, 2017, p. 28).
Each health care provider must sign (electronically or handwritten) the medical forensic record. There is no legal requirement that each page be signed. It is recommended that the documentation clearly notes which provider completed each portion of the examination and evidence collection process. Therefore, the Sexual Assault Medical Forensic Assessment Report and diagrams have initials on each page and a signature at the end of the report.