Patient’s History of the Incident(s)

Inform patients that the examiner:

• Will ask about the sexual assault,
• Needs to know what happened so that the examiner:
  • Knows what treatment to offer based on the health risks the patient was exposed to, and
  • Knows what parts of the body to collect evidence from, if the patient wishes to have evidence collected.

For adolescent or adult patients, examiner should ask them to start from what they remember just before the sexual assault occurred to when they arrived at the facility. To the best of your ability, obtain an accurate medical forensic history of the patient’s own statements, in quotations. Document an accurate history of the incident(s). Health care professionals are neutral receivers of the information.

For many patients, providing the history is one of the most traumatic parts of the examination. Using trauma-informed patient care techniques allows the patients to proceed through the examination process at a pace that is comfortable for them. The presence of a sexual assault advocate to provide support (i.e., provide comfort) may alleviate fear, stress and anxiety. Best practice is to use open-ended questions that allow for narrative responses.

For prepubertal children, the process is slightly different. Avoid extensive interviewing of children if examiner is not a trained sexual assault nurse examiner, specially trained medical forensic professional or a specially trained forensic physician. Clarification questions may need to be asked to ensure examiner has the full history, to provide appropriate medical care and treatment.

Offer patients the opportunity to write their history down if they do not wish to state it out loud. If patient can add detail, ask them to clarify unclear statements that are relevant to the medical forensic examination.

• For example, ask them to clarify what they mean by various terms related to body parts and to specify exactly which body parts had contact. Patients may prefer to indicate body parts by pointing on their own bodies or on body diagrams.
• Remind patients that the purpose of these clarifications is to offer appropriate treatment and collect relevant evidence.
• Examples:
  • “Is there something else that happened to you?”
  • “Is there something else I need to know?”
  • “Is there someone else I need to know about?”

To the best of your ability, obtain an accurate medical forensic history of the patient’s own statements, in quotations. Direct quotations are best practice (DoJ, 2016, p. 126).

Thank patients for providing the history once complete and acknowledge that it may be difficult to talk about. If typing the history on a computer into a document for printing, consider signing the document to include your credentials and date; delete the document from the computer if it is not a part of an electronic medical record.