Welcome to the International Association of Forensic Nurses Medical Forensic Adult Sexual Assault Examination video. My name is Jennifer Pierce-Weeks. I'm a registered nurse and practicing sexual assault nurse examiner. This video is meant to be a teaching tool to assist newly trained sexual assault nurse examiners in formulating their process for caring for the sexually assaulted patient. Our hope is you will find it useful in your practice. Please keep in mind this is one example. The conversation you see between Alexis and myself is not necessarily the conversation in its entirety. The video has allowed us to capture most, but not necessarily all, of our communication. In this video, I will walk you through the medical forensic exam of an adult sexual assault victim named Alexis. Naturally, everyone approaches their conversations with patients differently. You will see that my approach involves introducing myself to the patient and explaining briefly what my role is. I will also discuss with the patient her reporting options. You'll see that I emphasize the fact that what happened to her is a crime. This is very different than suggesting she should report the crime to law enforcement. It is not my role to choose for the patient, but rather make sure she knows what choices she has so she can make her own informed decision. We discuss anonymous reporting and evidence, but this varies from jurisdiction to jurisdiction, so you'll want to know your local approach. You'll also see me address consent for the exam in a brief fashion. The reason for this is that consent is something acquired all along the way in a sexual assault exam. If the patient signs a consent form initially and changes her mind during a later portion of the exam, consent has been withdrawn and must be respected. Patients who present after a sexual assault have been through a traumatic experience. It's important to inform them all along the way without overwhelming them with so much information, they can no longer process anything you're saying. Okay. How are you doing? Are you doing okay? I'm okay. Okay. Did you come right from there to here? Okay. Well, my job is to talk to you about what options you have, both for reporting and medical treatment. Okay? And so I'll go through that with you and make sure we address all of your concerns here. Okay. So have you already spoken to the police or have you thought about speaking to the police? No, I haven't talked to them and I kind of don't want to. You don't want to talk to them? What's your hesitancy? Are you worried about talking to the police? I just don't want to get anybody in trouble. Okay. That's a common feeling after something like this. Is that because you know the people who did this? One of them. Okay. Well, okay. Let me tell you what options you do have because you have several. And if you don't want to report today, you don't have to. Okay? Because how old are you? 21. You're 21. So as a 21-year-old, you have the right to report, of course, to law enforcement because it is a crime what happened to you. Okay? And you have the right to be here and get a medical exam with evidence collection if that's what you choose. Okay? You also, though, have the option of something we call anonymous evidence collection. So you don't have to speak with the police. You can opt out of that. But you can still have the evidence collection and the medical exam. And that evidence still gets sent to the police department and held there until you decide to report. And you have a two-year period of time. And it's different from place to place. Here you have a two-year period of time to make a report if you want to. If you don't report within that two-year period, they usually will have destroyed the evidence that we collect today. So that is an option, that anonymous piece. And the other option, of course, is having a medical exam without any evidence collection and just letting us see you and treat you. What do you think? I know it's hard to make decisions when you've just been through this experience. But what do you think you'd like to do? I'd like to stay anonymous. Okay. And have the evidence collected. Okay. I think that's a good option. Because a few days from now, the evidence may no longer be there. And so we might as well collect it while we can. Okay. Well, we'll plan to do that. And I'll be the one talking to you about what happened in more detail and doing the exam and the evidence collection. But the most important thing for you to understand is that you don't have to. If we come across some section of the exam you don't want, you don't have to have it. I'm not going to make you do anything you don't want to do. Okay? So if there's something that you want to just decline, you can just say, I really don't want that part. And I'll respect that. Okay? Okay. Okay. So typically what I will do is talk to you a little bit about what the exam is like and get your consent, your formal written consent for the exam. And then I'll get more of a detailed medical history from you, more of a detailed assault history from you. And then once we've done that, we can move on to the exam. Is that okay? Okay. Okay. So the exam itself, typically are you wearing the same clothes you were wearing last night? Okay. So typically if you allow it, I would want to collect your clothes for evidence. So I would actually set up some papers on the floor over there and have you stand over there so that I can collect your clothes. And after that I would have you come back in a hospital gown, sit back on the stretcher. And then I would do a head-to-toe exam, just like when you're at the gynecologist's office. Have you been to the gynecologist? Okay. So you've had a pelvic exam before. Okay. So I would just have you come sit back here, and I would just go from sort of top to bottom looking at your body, making sure you don't have injury, looking in your ears, listening to your heart, listening to your lungs and your belly, making sure everything looks okay. But as we go through that process, too, depending on exactly what happened to you during the assault, I may collect evidence from different places on your body. Okay. And once I have more detail about what did happen to you, we can talk about what you might need for treatment. Okay. Does that sound good? Okay. Then the only other thing I would mention is that if you have injury, we like to take photographs of that injury, so we have photographic records of the injury. That is up to you, too, but it's typically part of the exam if we get to the place where there's something that needs to be documented. Okay. So I'm just going to have you sign this consent. Okay. All right. Are you comfortable right where you are? Okay. So let me ask you this. I know you're only 21. Do you have any medical history to speak of, asthma, diabetes, anything you take medicine for? Nothing. Have you ever had surgery? Haven't had your appendix out or anything like that? Okay. Is there any medical history at all that you can think of? Six months ago I was treated for chlamydia. My boyfriend, I guess, was cheating on me, and I didn't know. Okay. But you got treatment. And are you still with him? No, you're not with him. Do you have a partner right now? No. No. Okay. And you're in college, yes? Okay. Are your immunizations up to date? Have you had things like the hepatitis series, tetanus? I think I'm current on my hepatitis. I don't know when my last tetanus was. Okay. And, yeah, typically you have to have a whole series of shots before you end up going off to college. So, okay, so you're unsure of your tetanus, but you're sure of your hepatitis. Okay. And do you remember when your last period was? About three weeks ago. And was that normal? And have you ever been pregnant? Okay. Are you on any form of birth control? Okay. And I'm just going to kind of take a few notes as we go. Okay. So I'm going to ask some questions about the assault itself, okay, and the more detail the better. The only reason I'm asking detailed questions is it helps me to figure out what you need for treatment and where I might find evidence as we go through the exam, okay? Okay, so I know you said you were at a frat house, that it was last night, and that there were two guys involved in this. Can you just give me an idea of what happened? Tell me in your own words what happened. Well, after they laid me on the bed, they pretty much just did everything. Okay. So they brought you up to a room, laid you on the bed. And when you say they did everything, can you give me a little more detail on that? Can you tell me what you mean? I mean pretty much everything you can think of. Okay. And you know one of them, you said? So what is his name? His name's Scott. Okay. I don't have any clues about the other one. Okay. So then I'm just going to separate those two out for a second and ask you some really specific questions about what they did, okay? And had you been drinking a lot or were you buzzed from something else? Just alcohol. Just alcohol, okay. So if you don't remember, it's perfectly fine to say you don't remember, okay? But the more that you help me with the details, the better. So let's start with Scott, the guy you do know. Did Scott put his mouth on you anywhere? He kissed me all through my neck. Okay. And did he put his penis in your mouth? He did. And in your vagina? And in your bottom? Okay, he did all three of those things. Do you remember did he wear a condom? I'm not sure. Do you know what the word ejaculate means? Okay, do you know if he ejaculated? I don't know. Not sure, okay. Okay, so set Scott aside for a second. The other guy, what did he do? The same thing. The same thing. So he also put his penis in your mouth, in your vagina, and in your bottom. And did he put his mouth on you anywhere? He kissed me in my neck as well. So, okay, kissed you on the lips and around your neck, okay. And have you showered since this took place? Okay. What happened? When they seemed like they were done, what happened? What happened next? Well, they did. Okay. And then what happened? How did you get to leave? Well, then we all kind of just passed out and fell asleep. And as soon as I woke up, I came in. Okay. I put my orange clothes back on and came in. Okay. And do you know Scott well enough to know, is he a man who has sex with men? Is he gay? Is he bisexual? I mean, obviously he had sex with this other man, but is that, do you know enough about him to know is that his usual behavior? I don't know. Okay. Do you know if either one of them use IV drugs? Okay. Remember, the examination is a medical one. You are incorporating evidence collection when the patient wants you to. Given the many health implications and treatment options following sexual assault, it's important that you focus on the patient's overall medical history as well as the assault history. You will see me explain to the patient the rationale for why I'm asking her such intimate and detailed questions. By giving the patient your rationale, you're able to decrease the likelihood that the patient feels you are somehow judging her. So I know you said you came right here from from the crab house that basically you got dressed and you came in, but did you shower in between times or have a bath? Do you know what a douche is? Did you use a douche? No. Did you do anything to clean your genital area at all? Okay. Have you brushed your teeth? No. Had anything to drink or eat? Have you gone to the bathroom? Have you peed? Had a bowel movement? Anything at all that has washed off your body in any way? No. Okay. All right. Very good. Thanks. In this next segment, you'll see how I talk to the patient about her treatment options, given the nature of her assault. Again, everyone does this a bit differently. I find it helps if the patient understands the rationale for what you're offering. You'll find a way that's comfortable for you. I specifically spend more time discussing HIV non-occupational post-exposure prophylaxis with this patient because of the nature of her assault, but also because this is an area that many nurses lack confidence or training. I did not avoid the rest of her options, but rather focused on this for the purpose of the video. Alexis, now that you've talked to me about exactly what has happened to you, I want to talk first, before we even go into the exam and evidence collection, I want to talk to you first about your treatment options. One of the reasons I want to do this is because you expressed a concern about HIV, and you have some options available to you. So I'm just going to talk to you for a few minutes about what you do want us to consider and what you don't want us to consider as we move into your treatment plan, okay? So bear with me because I'm going to ask you yes or no. Are you interested in this? So I know that you're not sure whether or not they wore condoms. I know that you're not on birth control pills or any other form of birth control, and given what they did to you during the assault, if you're worried at all about pregnancy, we have the option of giving you Plan B, which is a pregnancy prevention medicine. It is essentially a birth control pill. It's not the abortion pill. It's often confused with that, but it has nothing to do with that. We can't give it to someone who's pregnant, and even if we did give it to someone who's pregnant, nothing would happen to the pregnancy, okay? So it's essentially a birth control pill without estrogen in it, so there are fewer side effects, but it's 89% effective in preventing pregnancy if it's given within the first five days after the assault. You're well within that window. You're here five hours after the assault. Are you interested in that? Yeah. Yeah, okay. So we'll make sure you have that today. The other thing that we routinely offer people who have been sexually assaulted in your circumstance is treatment for the most common sexually transmitted diseases, so that tends to be gonorrhea, chlamydia, which you're familiar with, and then trichomonas is another one. Those three we can give you antibiotics for here before you leave. One of them is a shot. You said you were not allergic to anything, right? Okay, so one of them is a shot called rosepin. Another is a series of pills, zinframax, and the third is flagyl, which I would not give to you today because you were drinking last night, and so it can make you really sick to your stomach, but I would send you home with some, so once you've been, you know, 24, 48 hours since the drinking, you can just take those pills and don't have to worry about throwing up, okay? So those are three things that I would offer you too, given what has happened to you. Are you interested in those? Yeah. Okay, so then the third thing I want to talk to you about is the HIV issue. We do get concerned about that with people we know use IV drugs, people who identify as men who have sex with men. Clearly, they had sex with each other, but we don't know their HIV status. We don't know if they're positive or negative. If they're negative, you have nothing to worry about, right? But if they're positive, you have a very small risk of getting HIV. We do have medicine that we can give to you that can help prevent, it's not 100%, but help prevent you getting HIV, but it's complex, okay? And it's a lot for you to take in with everything that's happened to you, okay? So I want you to stop me if you have questions. I want you to just say, I have no idea what you're talking about. If I go, if I get too complicated, okay, but I'm going to try to explain this to you so that you can choose whether or not you want this option. So first, let's talk about the risk of getting HIV to begin with. There's no information on getting HIV from sexual assault, so we have to look at information from what we know about HIV. So if you were just choosing to have sex with someone, a guy, and that guy had HIV, if he just had vaginal sex with you, there's less than 1% chance of you getting HIV, even if you have it, less than 1%, okay? Really small risk. But if you choose to have sex with the same guy who has HIV, and he has anal sex with you, or sex in your bottom, then you have up to a 3% chance of getting HIV from him because he has HIV. That's significantly higher, but it's still really low risk, okay? But because the risk exists, all right, we have the opportunity to start you on some medicines. They're called antiretroviral medicines. They have all sorts of long names, but essentially they're HIV treatment medicines, but we would give them to you for a whole month to prevent, try to prevent you getting HIV if you were even exposed, okay? The most important thing for you to realize is you have to take them for a whole month, okay? And we would give you a starter pack here, and then a prescription to fill for the rest, but it's a whole month worth of treatment. We'll talk sort of about payment as we go along, but they can be very expensive depending on what you have for an insurance. If you don't have insurance, we can help you work with the pharmacies, the drug companies, to get those medicines paid for. So I don't want you to worry about money as you think about whether or not you want to try this treatment, but you have to take the medicine exactly as prescribed for the whole month. There are usually two medicines involved. One you would take once a day, the other you would take twice a day, okay? But the side effects, okay? The side effects are significant. You have class in college every day, I assume, pretty much every day, Monday through Friday, okay? So some of the side effects include nausea, vomiting, diarrhea. Well, those are side effects for most drugs, but the side effects that go with these drugs are significant, so much more severe. Experiences that patients have described to me are things like not being able to make it to the bathroom because the diarrhea was so bad, so much that it can sort of interfere in your ability to even get to class. So the side effects are significant. There are more serious side effects. It can sometimes bring on liver failure. It can interfere with your kidneys. It can, generally speaking, make you feel really, really sick for several weeks, okay? So you have to know that going into it, and the way that it is effective is if you take the entire series for the month. The other thing is, before we can start you on this, and if you choose it, we would want to start you right away on this, okay? Time is really important, and you came right in, which is the best-case scenario, okay? We would want to start you right away. We need to do a pregnancy test on you, which we would want to do anyway to give you the plan B that we talked about, but we also need to do an HIV test so that we can show that you're negative now, and chemistries and liver function, kidney function, a whole variety of tests, hepatitis series, and all of that we need to draw the blood first before we start you on your medicine, have that sent off, and then we would connect you with an infectious disease doctor, and that is who you would see in follow-up so they could repeat your lab work and make sure your liver is working okay if you're taking the medicine, your kidneys are working okay, everything is going okay. If you're sick to your stomach, they can give you medicine to get that to sort of go away or be less, so that's all a whole lot of information in a very fast fashion. What are your thoughts or questions about that? I'll think about it while we go through everything else. Okay, okay, that's fine. Yep, perfectly fine. Great. Okay, so then the only other thing I'm going to do is, one of the things we do here at this program is make sure that you get introduced to our community-based crisis center advocate, okay. So I'm going to have Nancy, our advocate, come in, give her a few minutes with you. They're the only organization here where you can talk to her all about what happened to you. She'll let you know what resources are available for you in the community, including things like victim's compensation, so if you need money to cover some of the exam or counseling after, that you have access to those funds, okay, but she has, she's the only person you're going to deal with that really has privileged communication, so you can really talk to her in confidence about everything and you can also see her after that, so they work with you if you end up needing counseling, okay. So I'm just going to get Nancy, introduce her to you if that's okay, and give her a few minutes to chat with you while I go set up the exam room, okay, and then I'll come back and get you and we'll go ahead and move forward into the exam. Okay. Okay, great. You watched me introduce both the concept of community-based advocacy and the actual advocate at the very end of the last segment. It's important to understand that how you introduce this resource can be critical to your patient's recovery. Introducing the patient to the advocate and giving them time to speak alone about available services is an appropriate approach, and remind the patient that the advocate is able to stay with them during the exam if they would like that support. Advocates offer ongoing emotional support and information to the patient in a way medical providers cannot during a one-time visit. Most patients will not opt to even engage in advocacy services if all they're given is a phone number to follow up. That is why face-to-face introduction is strongly encouraged. We want you to work closely with your local advocacy services in an effort to better meet the needs of sexual assault patients in the long term. Please also visit the IFN website for our position statement on advocacy following sexual assault. Now we will move through the physical exam. This should always involve a full head-to-toe review of systems including neurological exam, musculoskeletal and skin surface exam, cardiovascular and respiratory system exam, head, ears, eyes, nose, and throat, abdominal exam, and psychosocial. We'll look at the genitourinary and gynecological systems when we get to the anogenital examination portion. Throughout this review of systems, you'll incorporate your evidence collection based on the assault history details and the patient's consent to allow you to obtain evidentiary specimens. Please understand that collection techniques vary from jurisdiction to jurisdiction and program to program. So what you see in this video may not reflect the way you were taught. So Alexis, now that you've had a chance to meet with Nancy, I'm just going to go ahead and collect your clothing. So I'm just going to put this sheet down here, but don't stand on this one. I'm going to put a second one on top of it, and I'll have you stand in the middle of that, and then we'll collect your clothing. okay I'll have you right with your flip-flops come right out and stand right in the center there and I'm gonna get the hospital gown for you and you said you have two shirts a bra and shorts and undies right it's gonna set up some bags okay so what I'm gonna do is I'm gonna hold this gown up in front of you and I'm gonna have you start with your shirts and if you can just drop each article of clothing into one of the bags And actually, you can slide this on now that you've got the top parts off, and we can at least keep you covered. If you turn a little bit toward me, I will tie this for you. And you can keep your belt. So let's see. We have two more, yes? Set these aside while you do that. Yep, you can set that right there. Perfect. And while you're standing there, I'm going to have you just turn toward me. I'm just going to look at the backside of your body, okay? Make sure you don't have any injuries there, and I'm going to tie this up so you don't feel like you're just walking around the room naked. And then I'm going to have you turn toward me, and I'm just going to turn you this way, yep, and I'm just going to look at the front side of your body, okay? Same thing. Just make sure you don't have any injury there, okay? And you can go ahead and sit right back there. Now I'm just going to collect this top sheet, and then we'll continue with the rest of the exam. Okay, I'm just going to take a listen to your heart and lungs and we'll get started with everything. Can you take a deep breath for me and now? Okay one more time. Okay good. And how does your mouth feel? Does your mouth feel okay? Before I do anything I'm gonna first look inside your mouth okay and then I will collect some swabs from in there and then I'll have you rinse okay. All right I'm just gonna have you look this way a little bit. Do you have any pain in your mouth at all? Okay I'm just gonna flip your lip up this way. I'm gonna collect those swabs. So these are just four dry q-tip swabs and I'm gonna run them along inside your gum line and by your teeth. Okay, great. and I'm just gonna get you some water to rinse with and you can just rinse and swish your mouth and just spit it right back in the cup. That way when we go to do the the other swabs your mouth will be rinsed out. Okay I'm just gonna take a look in your ears. Did you get hit at all? Okay. Not having any pain in your head or your ears or your throat? No. Okay before I feel your throat I'm just going to collect swabs from wherever you tell me you remember them kissing your neck. Okay. And I'm going to wet the swabs first. So you give me some idea, was it one side or the other, or was it both sides? It was both sides. Okay. Make sure I'm hitting the area that we were talking about. I'm just going to have you raise your chin up a little bit. Good. Okay. And you said also they were kissing around your mouth, yes? Yes. So I'm going to wet some swabs and swab around your mouth as well. Okay, can I get you to lay down for one second? I'm going to just listen to your belly, get your belly. I'm going to raise this up a bit. Are you having any belly pain? And does it hurt at all if I push on your belly? No. Okay. Okay. You can sit back up if you like. As we move on to the anogenital portion of the exam, keep in mind the order in which you want to complete your exam. First, assess all the genital structures just by looking with the naked eye. Use labial separation and traction. If you don't have access to a culpascope, any handheld magnifying glass can improve visualization. If you have a culpascope, make sure you're properly trained in its use and use it for all of your assessments. You will not see me address this in the video. However, during your palpation of the genital structures, it is appropriate to ask the patient if she or he is having any pain or discomfort so that that can be documented. Okay, so I'm going to start the pelvic exam. You've said you've been to a gynecologist before and had pelvic exams. So the difference between mine and theirs is that I'm probably going to look for longer, but I'm also going to look through this culpascope here, which just is like having binoculars on wheels. It magnifies everything, but it allows me to see even really small injury. So I'm going to look a couple times during the exam with this, but I'll explain everything as we go. So let me just grab some gloves. And I'll have you slide your feet up here. Do you have enough room? Okay. Okay. Now I'm just going to move the blanket so I can see, but still keep you covered. Okay? So you're going to feel me touching you, and the first thing I'm going to do is just look at all the structures down here. And you're going to feel me pull on you a little bit here just to get a better look of the structures that are a little bit inside. Okay. Everything looks good. I'm going to try to slide my scope out here. We'll see how we do. Okay. Okay. I'm just going to take a look through the scope. okay and I'm also Alexis if I could let me just move this scope out of the way and one of the things I'm gonna have you do is I'm gonna have you bring your knees together and hold your knees up to your chest and I'm just gonna look at your bottom okay can you are you okay doing that okay and if it's okay with you I'm just gonna look with the scope again is that alright And before I finish this part so you don't have to stay up there for too long. Is it okay if I swab down there? Okay, so I'll swab there right now get that part over with and then we'll Finish the pelvic exam. So I'm gonna wet these swabs a little bit. Okay, just because that tends to be a little drier And You're just gonna feel me touching you you're gonna feel cold like I'm tickling around your bottom. It's just the swabs, okay Doing all right, okay Okay, you're good with that you can slide your foot back here you okay Next, if you collect external genital swabs for evidence, you would go ahead and collect those after your inspection and palpation if your jurisdiction requires collection of initial vaginal swabs prior to any intervention, you would do that now as well. Once the swabs have been collected if you use toluidine blue dye to highlight injury you would use that now Remember not all positive uptake of dye means injury Then to better visualize the hymen you would use your Foley catheter for assessment Now that we've looked at your bottom and we know you don't have any injury there and we've done some swabs there I'm gonna swab all around the outside here. I'm just gonna wet a couple swabs and swab all around the outside And one of the things also that I use, Alexis, is this blue dye that I just put on the outside down here to highlight any injury that you have. I'm just going to put a little of that on and remove it because it looks a little bit red there. And what I use to remove that is a baby wipe, okay, so it just kind of feels like a cool towel. You let me know if that bothers you at all. And what I'm seeing, just so you know, is a purplish abrasion across what we call your posterior portrait. It's just highlighted by the dye. So that's what I'm looking at, which is unusual considering what you've talked to us about today. The next thing that I'm going to use, Alexis, if it's okay with you, is this. It's called a Foley catheter. Usually it's put in for people to collect urine, but I'm putting it in your vagina to look because right around the entrance to your vagina you have the hymenal tissue, it's called the hymen, and the balloon blows up behind it and it sits on the balloon so I can look at your hymen and see if there's any injury. So this is the balloon. So once it's inside, I'll blow that up and then I'll look. Is that okay with you? Okay. Okay, so you're just going to feel me just sort of sliding this in. Shouldn't bother, shouldn't hurt, just kind of feels like there's something there. And a lot of patients say they can feel the balloon blow up, so that's the balloon right there. Can you feel that? You're just going to feel me pulling down on things here, looking around. Everything looks good. You doing all right? We're almost done. The speculum examination comes next for the female patient. Once properly inserted so you can visualize the cervix, assess the cervix and vaginal walls for any sign of disease, process, or injury. Then collect your vaginal and cervical swabs for evidence. If you're collecting cultures for sexually transmitted disease, collect the cultures now. Then after removal of the speculum, complete your bimanual exam if it's within your scope of practice. OK, so the last thing I'm going to do is the speculum exam. OK, when the speculum is in, Alexis, I'm going to collect some swabs from inside your vagina, a couple sets of swabs, and then I'll be done. OK, so you're just going to feel me touching you here. And you're going to feel me just push down on your pelvic floor muscle. And you're going to just feel that speculum sitting right there. That's just me pushing down with the speculum. And I'm just going to slide that in so I can find your cervix. You're going to hear a little click. You OK? Perfect. All right. I'm just going to get my swabs. And I'm going to do some swabs around the vagina. And I'm going to do some swabs of the cervix. And I'm just going to swab inside here. I'm going to swab the face of your cervix. And I'm going to do another set of swabs of your vagina. You doing all right? OK. OK. Now I'm just going to slide the speculum out. Great. Is it OK with you, Alexis, if I do a bimanual exam where I put my finger inside your vagina and just feel your cervix and your ovaries and make sure they are OK? That's all right? OK. So you're just going to feel my cold finger, OK? You're just going to feel it turned upside down. And I'm just going to move over here. You feel that? Does that hurt? OK. How about over here? Any pain? No. OK. OK. Just going to go over here on the other side. Any pain over there? OK. Good. Everything looks really good. You want to sit? Want to slide up? You've seen the typical discharge process. Keep in mind that it may be helpful to check in at the end to make sure the patient has not changed her mind about anything. Review what treatment options the patient has accepted and what may be outstanding for her to consider. Talk about any follow-up expectations and remind the patient about the community resources. And lastly, let the patient know how they can reach your program or other services should they have questions after discharge. How are you doing now that you have this all over with? Are you doing OK? Do you feel like you've changed your mind at all with regard to talking to the police? Still feel, OK. OK. And the HIV medicine? What do you think? I don't know. It seems a little bit extreme. Well, it's your choice. So you certainly don't have to take it. And that's a completely fine decision. If you change your mind at all, you probably have about 24 hours to change your mind and get started on the medicine. So you have a little bit more time to think about it. But the sooner you start it, the better. I would suggest, though, that you make sure you follow up. And if you're concerned at all, get tested. But so you've had here, you've had your pregnancy prevention. You've had your Plan B. You've had Rocephin for gonorrhea. You've had Zithromax for chlamydia. And I'm sending you home with Flagyl for trichomonas that you can take 24 hours from now. It's perfectly fine that you've opted out of the HIV drugs. And your evidence has been collected. And law enforcement will pick that up. And again, you have all the information in your discharge packet so that if you change your mind and decide to report, you can go ahead and do that. And you have the process written down. Nancy from the Advocacy Center has waited in the waiting room for you in case you have any other additional questions for her before you go. What else do you think you need? I think that pretty much covers everything. OK. Where are you going home to? Do you live by yourself? Do you have roommates? Do you live at home? OK. On the campus? OK. Is she a good friend? Yeah. OK. Supportive? Have you told anybody about this? I told her where I was going this morning. So she kind of knows. OK. And she was supportive of you? You feel like, OK. Do you feel like you can talk to your parents at all about it? I don't know yet. Not sure. OK. What about seeing these guys on campus? What about that from a safety perspective? Well, I mean, I don't know either one of them that well. I don't have classes with them or anything. OK. Good. Good. I feel like I don't think that that will be anything. OK. Well, if you want to, when you're back with Nancy, you might want to talk to her about that. She might be able to help you troubleshoot some of that. Is there anything else you think I can do for you? OK. Well, you have our number, and you can always call back if you have questions about anything in relation to the exam or follow-up. Just give us a call. OK? OK. Good luck. As I mentioned, I'm a senior. As I mentioned earlier, this video is meant to be a supplement to a complete didactic and clinical education program. And it does not capture the full exam. While you did not see me take any photographs of Alexis, photography is an important part of the medical exam. In child sexual abuse cases, photography from the perspective of the genital exam is really a must. It must occur, whether or not the child has injury. In regards to the adult, typically photography is focused on photographing the presence of body surface injury and any other findings that may be present. And from a genital exam standpoint, usually people either do photography or they don't do photography. We strongly encourage the use of photography so that it can be used for educational purposes at a later time. So we have included the following clip of the photography portion of another patient's exam. So you can see my interaction with the patient, including the consent process for photographs. What I would like to do also is take some photographs of the injuries that you have behind your ear, on your neck. You have a little bruise here. And then the bruising you have on your eye. Is that OK with you? OK. I'm just going to have you sign right there. And these photographs will stay with your medical record, which can only be released with your permission. So they're not going to go anyplace else unless you need them. But if you change your mind and you decide to report to the police, you want to tell them that you have some photographs in your file, because that could help your case. Another aspect of care in intimate partner violence is the provision of photo documentation. Photos for this patient population assist in accurately depicting the injury, but also assist in court should the patient wind up entering the criminal justice system. Cameras are no longer expensive and provide excellent quality images. Health care providers should recognize the images as an additional form of documentation and make sure accompanying written descriptions are with them. Lastly, photos documented by health care providers must remain a part of the medical record with the same applicable HIPAA rules. First, we want to make sure that we First picture that I'm going to take is just you sitting there. You don't even have to look at me. You can actually look this way. It's not like going to have your picture taken someplace else, because it's for a different reason entirely. And then the next photograph I'm going to take is of your eye. I'm going to take it with this ruler in the picture and without. So I'm going to actually have you shut your eye for this. And hang on, I'm just going to put my ruler up against it. We hope this video has been helpful as you formulate your own process in caring for the sexually assaulted patient. Remember to follow your facility and jurisdictions practices, policies, and procedures. Additionally, there are a plethora of resources available to you through the International Association of Forensic Nurses. Good luck in your practice. Thank you.

medical forensic exam

sexual assault victims

nurse

reporting options

evidence collection

consent

treatment options

advocate

physical exam