Hello and welcome. Thank you for joining this webinar titled At Second Glance, A Review of the Medical Forensic Chart and Patient Photos. Today's webinar will cover just that, an overview of two patient encounters. My name is Nicole Stallman and I'm one of the forensic nursing specialists with the International Association of Forensic Nurses. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. Thank you to the District of Columbia Forensic Nurse Examiners or DCF&E for allowing me to use my patient encounters today to conduct this case review. Due to the nature and content of this presentation and out of respect of the patients presented here today, both myself and DCF&E do not authorize copies of this presentation or photos to be duplicated in any manner. Also, full disclosure, please know this is a case review and photos with varying degrees of injury will be displayed throughout including genital photos. It is our practice and within our policies and procedures to capture photos of all areas of the body, this being for photos that are either shared with the attorneys when we receive a subpoena, injury or not, and for the purposes of our peer review process. So that's our policy and procedure at DCF&E. As we go through the slides, you'll see information that has been blocked or redacted. So, for example, patient identifying information that will be redacted just for the safety of our patients. At the conclusion of this patient case review, participants will report increased knowledge of various patient encounters related to sexual assault, identification and documentation of injury using photographic images, and lessons learned related to quality improvement and medical forensic examination documentation practices. Before we start, let's talk about quality improvement and peer review. So what is peer review and what is quality improvement? Well, peer review is essential to validate findings, educate providers, improve our practice, and to assist in developing policies and procedures. Quality improvement is an ongoing effort to achieve measurable improvements that improve health care. It's important to develop a quality improvement tool within your program, not just a tool, but a policy and procedure that will be available for the nurses to follow. That policy, for example, could include that the medical forensic records and photos will be 100% peer reviewed, and every nurse must peer review a given number of charts per month. Having a peer review policy and process in place not only supports growth within the team, but improves everyone's practice. Everyone is learning from one another, and maybe they are finally seeing injury that they haven't seen or encountered before, or prior to peer reviewing these charts, that is. It's also a way to highlight work conducted and discuss the opportunity to make change and adjust those records. The quality improvement tool could consist of yes, no, or not applicable questions, a simple template, if you will. For example, here are just some ideas that you could include in your quality improvement tool. Is the demographic information complete? Is the investigative information complete? Did the patient sign the appropriate consents? Did the nurse date and time the record as well as sign it? Is the record free of grammatical errors? Was the record 100% completed or to the best of the nurse's ability? Is the chain of custody complete? Were vital signs documented? Does every injury align with the numerical findings for each description box? Were the description boxes for the findings completed? Are photos captured or were photos captured? Did the photos include bookends? Did the photos capture rule of thirds? Was the SBAR or nurse's note completed? Were medications provided? Was education provided? Did the patient receive follow-up resources? And did the patient connect with advocacy? These are just some general examples that could be used within your quality improvement tool to help guide your peer review process. All right, let's start with our first patient encounter. So this is patient SS who is a 33-year-old African-American female. She presented to the emergency department status post sexual assault. When I was dispatched, the dispatcher reported the patient was sexually assaulted by a stranger at her place of employment around 9 a.m. on the same day as the exam or on the same day as the exam was conducted. And the exam began around 11 a.m. on that same date. Dispatch also mentioned that the sexual assault unit and law enforcement were both involved and that an ambulance brought this patient to the hospital. Our partner advocacy agency was present for the exam. They present for every exam, for every patient encounter. We simply reach out to one another and ask what our ETA is or estimated time of arrival to the facility. And this is just to make sure that we are able to connect with that patient together at the same time going in as a team. And that's done to the best of our ability. I'll also mention that this patient encounter was nearly eight to nine years ago. So please keep this in mind as we go along. The patient was medically cleared by the physician and imaging was conducted. So after the patient was cleared, I was able to begin my medical forensic exam. I identified the patient as my patient and as requesting that medical forensic exam services as well as resources. I addressed the patient's safety concerns during the same time. Her questions were, where is this person that assaulted me? Did law enforcement catch him? Are my coworkers safe? Is anyone connected with my family? So those safety concerns were addressed. I talked through the consent process with the patient and obtained a consent, a signed signature, if you will, for consent. So that consent process included consent to conduct the medical forensic exam, consent to release information to advocacy, consent to release evidence to the sexual assault unit, and consent for approval to review this patient's case during our SART meeting. And SART is that sexual assault response team. Those are four different consents for signature. So we have four different consent forms that the patient signs, including an additional one that goes within the actual medical forensic record. It's important to note that I mentioned I obtained signature for these items, but it's the patient's decision, their consent to release any of these items to any of these partners. This is a process that I walk through with every one of my patients. And we should get in the habit of walking through the consent process with the patient, not just handing them a piece of paper and having them sign after they're done reading it, because it's likely that they're not understanding that legal jargon that's held within the consent process. So I encourage you to walk through the consent process with your patients, truly making sure that they understand what it is that they are signing. All righty. This slide shows for demographic information. I already noted that the patient's initials were SS, and she is a 33-year-old African American female. The medical record number and hospital account number are documented within the medical forensic chart, which helps further identify the patient on potential follow-up, such as when we call for labs, imaging results, toxicology results, et cetera, or if there are any kind of payment issues. The billing and coding department use the hospital account number to identify the patient's encounter. These numbers come from the patient's hospital labels or the hospital chart. I should also mention the program that I work for is a nonprofit organization. It is separate from the hospital, and the nursing staff are considered contractors of the hospital that we respond to. So it's important that we capture accurate information here, because we don't have access to the hospital system records. And when the billing and coding department call us for any kind of payment issue, we will have documented their medical record number as well as hospital account number as a way to trace back to that patient. We obtain contact information, phone numbers, email addresses, address, which is, again, helpful for identification purposes, but again, for follow-up. So the first arrow here is pointing to the resident type, and why do you think it's important to capture this information? Why do we ask about resident type? That's right. We must identify the patient's current housing situation and see if they are safe. Maybe they say they are homeless, so we document this as no fixed address. So maybe we provide various resources for shelter needs. Or we need to assess if this is a shelter, and maybe we need to provide additional assistance to seek in a different shelter. Maybe this is a domestic violence patient, and we need to ensure that they are safe in this location or, again, provide additional resources. The second arrow is pointing to a box that states, is it okay to contact? This is a patient's decision, but again, based on safety. Maybe they don't want us calling their cell phone as someone is monitoring their calls, voicemails, or text messages. You can see my third arrow here is pointing to the telephone number. If I was peer reviewing this chart, I would most likely ask the nurse why the phone number was not documented. For this particular patient encounter, the individual who assaulted her took her cell phone and a reason why she did not want to supply it at that time. She was sure to obtain our office number for any kind of follow-up, and she reached out to us. The fourth arrow points to the patient's ethnicity, which I have documented as Black, as yes, this is what the patient identified as. But I wanted to make sure that we are inclusive and consider expanding this question when we're asking our patients their ethnicity, not limiting this question to Black, Asian, white, or other, because what does other mean, and how do you evaluate that? Something our program has changed or expanded on over the years, so it's important to get in the habit of updating your records and being inclusive of every single patient. The last piece of information that I'd recommend updating is gender. As you can see here, this chart simply asks the patient's gender, but it's not inclusive of the patient's sex or gender identity. As healthcare providers, we need to be inclusive and respectful of all, so just something to consider. You will see this chart evolve over the next few slides, especially during the next patient encounter. So not shown here is the date and time of our exam, the forensic nurse examiner information, which would have included my name and signature, as well as the signature from the patient capturing that last consent to conduct the medical forensic exam. The information about the sexual assault unit detectives, their name and contact information is also not shown here, and the CCN or chief complaint number associated with that patient, but please know we do capture that information within our medical forensic record. Before I move on, I'll mention again that this case was from eight to nine years ago, so as we go through, I'll be sure to highlight various items, including various areas for room for improvement. This slide is of the patient's medical history. The patient stated she has no known drug allergies, which we will keep note of when we are prepping or offering medications. They denied any current medications. Also something we're going to make note of when we're prepping for medications. Her last menstrual period was documented, along with GNP or gravida and para. So that would be the total number of pregnancies or the total number of births. And please know you can further break this down to term, so delivered after or over 37 weeks, preterm, delivered prior to 37 weeks, abortion, which could be anything abortion-wise, miscarriage, ectopic pregnancy, et cetera, or living pregnancies. This patient is up to date on our hepatitis B vaccine, which is great, but unknown to our tetanus status. Denies any past medical history and any anal, genital surgeries, treatments, or procedures in the past 60 days. Why do you think it's important that we're asking this question? Why do you think it's important that we're asking about anal, genital injuries, surgeries, treatments in the past 60 days? Well, if you said it's important to ask in case they had a pelvic exam recently or any potential surgery, that's a great response because we know as healthcare providers that that could lead us to potential findings or any kind of varying degree of injury. So we have to note that. And also if we have any or encounter any injuries, we're still documenting that within our medical forensic record. On the right side of the screen, you will see a few boxes for consensual sexual activity. In this case, well, during this rendition of the chart, we asked about consensual sexual activity in the past three days. This is important to capture general information about which body part comes into contact with what. And please don't limit this information to the list noted here. Consider information or adding kissing, saliva, other body parts involved, et cetera. It's important to add. And we'll talk more about consensual sexual activity with our second patient encounter. So here is the patient's history or description of the assault. Please know there are errors within this narrative. Definitely areas are room for improvement, but you'll see that as we go through it. All right. So this patient states in quotes, I walked into the building at 840, 845, and I saw a gentleman standing in the lobby area. I was impassive and walked by. I turned the alarm off to the office. After opening the door, I turned the lights on, went to the desk, went to my desk, sat down and looked at the internet. I wasn't there long. I went to reach for my charger. The maintenance guy whose name is redacted came into the office, grabbed a radio left and didn't lock the door. I usually keep the door locked until 9 a.m. I looked down at my desk and heard the door open. The man came through the door. His pants were down. His penis was out. I asked, what are you doing? He said, I'll tell you what's about to happen. You're going to suck my dick or I'm going to kill you. I had my phone in my hand and it was about I was about to call 911. He saw my phone and came around the desk. He told me to put my phone down or I'll hurt you. I put my phone down. He said, put my dick in your mouth or I'm going to really hurt you. He pushed my head where his penis was and put his penis in my mouth saying, you've done this before. You know what you're doing. I opened my mouth and he put it in. I didn't do anything. He grabbed me and pulled me up, choked me with his arm from behind. At this point, I messed myself. In clarifying question here, in quotes, the patient stated, went to pee and poop in my pants. He told me to lay down. I got down. He put his hand in my mouth, unbuttoned my shirt saying, let me see them. He put his mouth on me, clarifying where and indicating left breast. Then he said, I'm going to move my hand. Don't scream. He went to unbutton my pants and noticed I had messed them. He said, you nasty. I said, I didn't do it on purpose. He asked, where was my purse? We got up and he reached under the desk and grabbed my purse, saying things like, my dad taught me how to hurt people. He reached for the phone and grabbed the cords. He told me to put my hands together and that's when he tied my hands together. He pulled my wallet out and looked at my address. Don't call the police because I know your address and I know people and I will hurt you. He was asking for pin numbers. He was asking for the pin numbers and I told him some fake ones. He grabbed my phone and took it, asking me to unlock it. He has it. He was asking about my co-worker and where she was. He said, we are going to try this again. He put his dick in my mouth and forced my head to do it. He said, I'm going to come, so you better swallow it or I'll kill you. He kept forcing my head and came in my mouth. I took the newspaper and wiped my face and shirt off. He said, you did good. You're my girl. Do you love me? I said, yes. He gave me a kiss. He said, give me a kiss. He kissed me. After that, he went to the fridge and took some food. At this point, the maintenance man came to the door. The man heard him and that's when he just walked out of the office. I started crying and the maintenance man again asked what happened and he said, call the police and that's when I did and the ambulance drove me here. This was a tough patient narrative, but it certainly captured what happened to the patient and because of this, I'm able to guide my medical forensic exam. I would have certainly clarified if anything happened to her vaginally, as I would not subject this patient to a vaginal exam, rather the focus assessment to the face, mouth, lips, neck and breasts. Also, going through this patient's narrative and description of the assault, there were a number of grammatical errors that could have been addressed prior to submitting this chart. The chart is peer-reviewed, so other nurses review this chart, but the patient is reporting to police, so law enforcement receives a copy, the crime lab receives a copy, the attorneys receive a copy, and the list goes on. But here you can see misspelled words, end quotes that with no beginning quotation marks and vice versa, improper pronouns used, well in the context of the situation, etc. So I just like to highlight the importance of checking your work. And I'll never forget this, but a colleague was providing fact witness testimony, probably my first experience ever viewing a court case. And the defense attorney had asked the nurse about grammatical issues within the record. And because of those grammatical issues, were there other errors, or what other errors could be found within the record as far as injury documentation or evidence collection goes? The nurse handled the situation beautifully on the stand, but I don't think I would ever forget the attorney's question. And a reason I might spend more time properly capturing the patient's description of the assault, their narrative, and reviewing it before I'm submitting the medical forensic record. So just some things to consider or think about. So you can see here all the errors that I had noted, but we'll go on. So follow-up questions after the narrative are somewhat necessary, right? Because as healthcare providers, we know the patient just went through a traumatic event and a million things are preoccupying their minds, and maybe can't recall every detail at this time. Also, sometimes they minimize injury. So if we're not outright asking these questions, they might not endorse this information. So we must ask particular questions such as yes or no. And in this case, we're asking particular questions such as yes or no. And an example here is, were you strangled? You can see on the documentation, it says, was the patient strangled? You can see the question within the medical forensic record was the victim strangled? This question is what I'm going to ask the patient. Did the person strangle you? Did the person put their hands or arms or any ligature around your neck? And you can see there the response that I received was in quotes, he choked me, something I'm capturing in quotes. And so we are all on the same page. Choking is an internal obstruction of the airway, whereas strangulation is an external pressure applied to the neck or any given area of the body. So again, choking is that internal obstruction of the airway, whereas strangulation is that external pressure applied to the neck. The other question is, was the victim threatened or injured with a weapon? Being that a gun, knife, or object, etc. But I have cords documented here. Is anyone wondering what about those cords? Maybe I should have clarified what kind of cords. Something pulled from the office or did this person carry something in? Again, I'm not a detective or investigator, but I could have clarified further. I could have said phone or computer cords as this is what the object the patient stated that she was tied up with. On the bottom of the slide, you will see a description of the assailant, which includes a number of assailants, their description and relationship status. The box for number of assailants was not documented and it should have been. This is something that I could have captured within the peer review process or on that quality improvement tool. That information is not listed here, so definitely something I would have asked on that QI tool. Under the description, so we used to ask a description of the assailant or every assailant that was involved. But again, that's investigative and we have since omitted this portion of the chart from our medical forensic record. Also, using the word assailant could be viewed as bias. So maybe considering changing that word to subject or individual, however you want to describe it. Again, emphasizing the word assailant could be viewed as bias. We simply left the section as the relationship status, so whether that is a stranger, brief encounter, acquaintance, family member or intimate partner, we still have that relationship status within the medical forensic record. So based on the patient's narrative, what kind of injuries or findings would you anticipate encountering? Thinking about what we went through just in that narrative just now, what do you think are some of the findings that we'll see with this patient? Would you anticipate bruising, abrasions, lacerations, or any of those things? Would you anticipate bruising, abrasions, lacerations, discoloration of varying shades of colors, swelling, maybe subconjunctival hemorrhage, tenderness, erythema, or ecchymosis? How about petechiae, pain, or a pattern injury? If you said any of those, that's wonderful. I'll also say this is a mnemonic, a little helpful tool that will help you recall maybe any potential injuries that you'll find, and you can use that as bald stuff. So you can see there bruising is B, abrasions A, lacerations for L, that goes on. But what about no findings? Is that a possibility? It certainly is. There are often times when we have patient encounters or when we have patients in our exam space and we do not encounter any kind of findings or injuries, but it's important to recognize that this does not mean that an assault did not occur. This slide shows for our contact matrix, as in which body part touches which body part. Both of the patient's narrative and the contact matrix, this helps guide our medical forensic exam. Again, the assailant has been removed from our chart, but you can see here in yellow that depicts the assailant's body part, and in green is the patient's body part. To follow this matrix, we would ask our patients if they could recall if the assailant's mouth touched their mouth, if the assailant's mouth touched their breast, if their mouth touched their vagina, if their mouth touched their anus, if their fingers touched their mouth, if their fingers touched their breasts, and we go through the entire contact matrix just like that. If I ask the question in reverse, so did your mouth touch their mouth, did your mouth touch their penis, etc., that places blame on the patient, and that means that I'm not being trauma-informed or patient-centered. So in this case, I ensure we are asking about the subject's body parts first. So again, just something to keep in mind, and then we can body parts first. So again, just something to consider, and I will also mention that this contact matrix is no longer within our medical forensic record. You'll see that on the next patient and how it's changed or how it's evolved since. Also, it's important here to not be re-traumatizing or re-victimizing your patient during this matrix. So yes, the patient's narrative is a way to guide our exam, but we further ask these questions in case there's any kind of something that was missed during the narrative. But again, we're not being re-victimizing or re-traumatizing here. Here's the beginning of our physical exam. You can see here that I collected the patient's vital signs, something we do for every single one of our patients, as this is a part of the thorough head-to-toe exam. If the patient's blood pressure was elevated, for example, we would be sure to evaluate the patient further, inquire of current medications, including compliance, notify the physician, and address the issue before sending this patient out the door. Because our exams are medical in nature, we need to make sure that we are following up properly with our patients. This section also includes general demeanor, emotional state, and mental status. This patient is alert-oriented to name, date, and location. Their airway breathing circulation is intact. Speech is clear, which should always be assessed, especially with complaints of strangulation. The patient was complaining of pain in their head, neck, and throat, and noted here that she was answering my questions appropriately. Also included in this section is general appearance, including the condition of their clothing, which is documented as the patient is being well-kept, positive for a white substance on the black top, and positive for loss of bowel and bladder. Because of this, I might question or clarify on the quality improvement tool during the peer review process what I meant by being well-kept. Just something to consider about as we move on into the rest of this exam for this patient. All right, so let's make our way into the head-to-toe exam. In full disclosure, again, there will be graphic photos of findings or injuries that will be displayed throughout the rest of this webinar. So, here's our first set of photos. When you're looking at these two photos, what are you, what kind of findings do you see? Does anything stand out? Think about any colors you're seeing, shape, sizes, the location they are located at. Again, this will help you understand what you're looking at, and what you're not seeing. So, let's go ahead and take a look at the the location they are located at. Again, this will help guide your documentation. Excuse me, I'm going to go back. I'll give you a few seconds to look these over. I will also mention that most all of these photos have been cropped just so we're de-identifying the patient specifically for this webinar. You'll also see various boxes, so we're not further identifying this patient either. So, what do you think? What are we seeing? For documentation purposes, here is finding number one. Please know this is the same photo that was displayed on the last slide. Is anyone asking, what is that? Or is anyone saying, well, I see an area of redness to the right eye? If so, that's great, and you're describing what you're seeing, and that's perfect. How about taking it a step further? How about saying subconjunctival hemorrhage? Did anyone think to say or mention that as a finding? If so, that's awesome, because that is exactly what we're seeing here. So, what is subconjunctival hemorrhage? Well, let's break that down a little. It's bleeding underneath the conjunctiva, the clear lining of the white of the eyes. I'd also like to mention that a subconjunctival hemorrhage can be present with coughing, sneezing, projectile, or relentless vomiting, or even straining to have a bowel movement. Those are just some examples. And that's same for petechiae, which we'll talk about in the next slide. All right, so if I were to take that information and add it to the description box, what you're seeing there, you would see a number one in the finding. My description is a subconjunctival hemorrhage. The comments would include that this is a finding located under the right eyelid. The patient denied any vision changes, and it was photographed. I did not capture a length and width for this injury. You can also see here the importance of proper assessment. So, you can see that I'm pulling downwards on that patient's eyelid. If we didn't pull down on that patient's eyelid, we would never have found that injury. So, it's important that we're pulling down on the eyelid, having that patient look in all directions, as well as lifting up on the upper eyelid to see what's under the upper eyelid. So, important thing to incorporate into your practice. All right, so here's finding number two. Please know that this is a second finding. It's separate from our first finding or injury. So, what do you think we're looking at? I kind of gave it away in the last slide, but we'll say it again here. If anyone said petechiae, that's wonderful, because that's exactly what we're looking at. This photograph is just one section of the patient's face. Again, this photo was propped for the purposes of this webinar, but please know that petechiae was found circumferential to this patient's face, as well as scalp. Just moving or parting her hair, you could see petechiae throughout her scalp, throughout the hair. The description here would be petechiae, and the comments would include multiple purplish red non-elevated pinpoint spots to the patient's face and scalp. This finding did not include a length and width, and the ALS was not available for this exam. So, you can see here just a few arrows of where that petechiae was noted. Again, it was everywhere in this patient's face, just so you're aware of that. Looking at these photos, what are you seeing? Does anything stand out? I'll give you a few seconds to look those over. If you said multiple linear red abrasions, you're absolutely correct. Again, we're documenting what we're seeing, but did anyone consider mentioning a pattern injury? If so, you're a rock star. A pattern injury is from a tool or object which created it. In this case, the earring created these multiple linear red abrasions, which we know are related to the patechiae. So, earring created these multiple linear red abrasions, which we know are related from the assault or related to that assault, potentially related to that strangulation. But again, we're documenting what we're seeing. Also, not to confuse anyone with the pattern injury versus pattern of injuries. So, again, pattern injury is that which a tool or object created it. And a pattern of injuries is defined as multiple injuries inflicted on various states and times that are in various stages of healing. As far as critiquing these photos, thinking about the peer review process, this would be a depiction of rule of thirds. One image, so the image on the left, excuse me, is the one that's farther away to identify where it is on the body. The middle photo is a third closer to capture a better view of that injury. And then the left, the far right photo is that of with the use of a ruler. Please know that last image is blurry. So, multiple photos were captured to obtain one that is in focus. It was not included in this webinar just so we could talk about it, how it's important that if you're going to take a photo, keep it in your series, don't delete your photos. But you can certainly obtain a better one so that you're capturing everything that's in view. So, this image here is of a pattern injury. As far as documentation goes, you'll see my body diagram has an arrow pointing to number three, an arrow leading to where it is located on the body. The documentation would be typed out in that description box. So, this would be finding number three. The description would include a pattern injury. And in the comments section, I would document the pattern injury with multiple linear red abrasions with area of redness noted to the postauricular area or the area just below the right earlobe. The length and width were measured in millimeters. And I would have checked that, yes, the photographs were collected during this time. Looking at these series of photos, what findings do you see here? Is anything standing out? And if you're considering how would you document these findings, that's wonderful of you. Way to take that a step further. So, what are we seeing? I'll give you a few seconds to look those over. Here's the same photo from the previous slide. As far as the documentation goes, this would be described as number four. Did anyone say a circular reddish purple discoloration noted to the dorsal right hand? If so, that's excellent because you're documenting what you're seeing. So that description number four would be the suspected bite mark with circular reddish purple discoloration with central discoloration or bruising noted to the dorsal right hand. Length and width would have been captured in millimeters. And if anybody can remember, we did not hear anything about a bite mark, correct? During the narrative. So that is something that I would have asked the patient or clarified further when I made the assessment. And maybe it wasn't a bite mark, but it certainly looks like one here. After I clarified with the patient, she said, yes, I remember that the individual bit me here. So that was documented as a suspected bite mark per patient. Is there anything else you're seeing in this photo? You can see here that I have a number five demarcated on the body diagram. And yes, that's correct. There are two linear red abrasions. That is a pattern injury because we know based on the narrative that she said she was tied up with cords. And that pattern injury was created with those cords. So two linear red abrasions. For this patient's photo, for this patient's head to toe exam, that was the extent of the patient's findings, physical injuries, if you will. For your knowledge, I did not see any petechiae in the ears, in her mouth. And I didn't find any dental injuries or abrasions to her gums or lips. All right, so we're going to move into evidence collection. Here is the PERC, the Physical Evidence Recovery Kit. Some call it a SAC or a Sexual Assault Kit. Some call it a SAC or a Sexual Assault Evidence Collection Kit. It just depends. We call it a PERC in the District of Columbia. So based on the information we talked about today, what areas of the body do you think I swabbed for evidence? For what articles of clothing do you think I collected? You think I collected a known sample, lip, oral or breast swab, thigh, external genitalia, perineum, vaginal or cervical swab, perianal or rectal swab? Did I collect this patient's shirt, bra, tank top, underwear or pants? All right. From the PERC, I collected a known sample, which included a finger PRIC and a few drops of blood. I did a lip swab. I did an oral swab, chest swab, given that substance. Chest, breast, given the patient's narrative and fingernail scrapings were collected. The clothing that I collected included a black shirt in a tan tank top and underwear. Here are some items to critique. Items that I would certainly include on a quality improvement form or that during the peer review process. Can anyone remember my slide on general appearance? This patient was well kept, but had loss of bowel and bladder. Why didn't I collect the patient's pants? This is evidence of the patient losing bowel and bladder, whether that was from a reaction of fear or the reaction of the traumatic event or that patient lost bowel and bladder due to the loss of consciousness related to strangulation. That's evidence and something that I should 100% have collected and I did not collect. So in hindsight and looking back, I will collect every single pants as needed in a probative manner. Can anyone remember my slide on the suspected bite mark? So why didn't I collect a swab of that right hand where the patient was bit? That would have been great evidence to collect. And I certainly didn't. So that's something else I would have asked in the peer review process. Thinking about the photos, I certainly could have captured a photo of the mouth in case there was a follow-up exam. We might have found maybe progressing injury. But just some things to consider or think about there. I have here the National Institute of Justice, excuse me, the National Best Practices for Sexual Assault kits, multidisciplinary approach. And within that resource, it's a great resource to highlight the various areas of the body that what you need to do as far as evidence collection goes, the timeframes of every body area for evidence collection, and then how to swab them accordingly. So I encourage you to look at that document. Here you can see the patient's black top and the white substance that was noted on the front. So I collected this patient's clothing and packaged the top appropriately in a paper bag. This is to avoid cross-contamination. This shirt was packaged separately from the tank top as well as then separately from the bra or underwear. These items were photographed and packaged. I did not swab the substance as we let our crime lab analyze and handle all clothing. A DC Crime Victims Compensation application was completed and signed by the patient. The form was submitted and the patient received a reimbursement for clothing. This application ensured she was not billed for her 28-day dose of NPEP and assisted with having her locks changed. This patient was eligible for Crime Victims Compensation because she simply fulfilled the requirement of having the medical forensic exam, which remains true for all of our patients in the District, whether they report to police or not. And it's important to mention here that every state, territory, the District of Columbia, the military, and Canada have a summary of their billing and payment process, all housed at safeta.org. That webpage will be provided in the resources section of this presentation. Each location has a Crime Victims Compensation application as well as brochure within their designated locations webpage. So again, another great resource to look into and make sure that you have this information available for your patients. Here's the provider summary page and SBAR of what happened during the encounter. The 33-year-old African-American female presented to the hospital with complaints of sexual assault that happened around 9 a.m. today. Medical screening and the medical forensic exam were completed after a sexual assault by an unknown assailant per patient's narrative that occurred today. The patient is alert and oriented times three. The ABCs or her ABCs were intact, so airway, breathing, circulation were intact. Speech is clear. The head-to-toe exam was completed. Findings include subconjunctival hemorrhage to the right eye, fatigui to the face and scalp, pattern injuries to the right posterior ear with multiple linear red abrasions, suspected bite mark to the right hand, two linear abrasions to the right wrist. See medical forensic chart for specific details. The patient is aware of the plan of care and follow-up with infectious disease advocacy and the forensic nurse examiner's offices. The doctor is aware of the exam and findings and medication administration. The CVC or crime victims compensation application was completed. The patient states, in quotes, I feel safe going home, and the patient was discharged home. You also can see here the medications that were provided. So I collected labs from this patient, which were sent to the hospital lab for analysis, and that included a CVC, CMP, LFT, RPR, and HIV. Medications that were provided to the patient included ceftriaxone, 150 milligrams IM injection, azithromycin, one gram by mouth, Motrin for pain, received a tetanus, and a three-day dose starter pack for NPEP, that non-occupational post-exposure prophylaxis for HIV. During this time, we were providing Truvada and Isentris, and Truvada should be administered once per day, and Isentris can be, or should be taken twice per day. Patient discharge instructions should include, but not limited to, patient education regarding their injuries, the healing process, any questions that they may have, medications provided, so during the encounter, why were we providing medications to that patient, what are they used for, the side effects that they may experience, all of the information you can think about regarding medications. The medications the patient is going home with. So for example, if the patient was given Flagyl, information should be provided to that patient about why they're taking it at home, especially if alcohol is on board, or side effects or general side effects of it, or if they're provided a script for NPEP, again, that non-occupational post-exposure prophylaxis for HIV, so were they given a script, do they have to go pick it up at the pharmacy, were they given a three-day dose starter pack, or do you guys supply the patient with a full 28 days? That information should all be included to your patient on discharge. Medications to pick up at the pharmacy, so that script for NPEP, or an anti-nausea medication, were any of the medications that your facility provides scripts for. A discussion around safety and addressing the patient's concerns. Just as the National Protocol for Sexual Assault Medical Forensic Exam states, we must address the patient's safety. So I not only addressed the patient's safety throughout the course of the exam, but we ensured that we talked about safety during the discharge process as well. Follow-up discussion should include information that is related to follow-up testing for STIs, HIV, and pregnancy, and when to return for testing, and that should be one to four weeks timeframe. Follow-up discussion related to advocacy and the resources that they're able to provide, and incorporating them within the plan of care as soon as possible. Providing information about law enforcement and their contact information, and if the patient is not ready to make a report with police, they should still be offered that resource in case they change their mind overnight or the next day. That information should be provided to the patient. Any information about kit tracking database, or provide information regarding their kit tracking, so providing that patient with a way to locate their kit in the system, including the website, so the patient can be aware of where their kit is. Payment for the exam and answering any patient questions should be included in the discharge process, so who pays for this exam? What services are covered? Will they receive an ED visit bill? Will they receive a bill from the CT scan or other physician assessments? Will that be included in the bill? Help completing that crime victim's compensation application with the patient. That should be included on the discharge discussion. Notifying the patient that the program will call and follow up with them within a few days, follow-up regarding how they are tolerating their medications, if they are receiving or have received their remaining 25 days of NPEP. Have they conducted or follow-up call with their primary care physician? Have they connected with them, or do they need a free clinic to receive follow-up? And that follow-up being for that STI, HIV, and pregnancy testing. Again, those are just some examples that would go in your discharge instructions, but I encourage you if you have others, don't limit yourself. In regards to patient follow-up, our practice is to call every single patient and counter, see if they need anything, see if they have made the various appointments with their PCP, see how they're tolerating medications, connect them with the pharmacy, all of that information we call all of our patients, every single patient and counter. We also assess for any nausea or vomiting, if they have any other signs or symptoms or anything that they would like to address at that time, we talk with the patient in length. For this particular patient and counter, the pharmacy delivered the remaining doses of NPEP to the patient's house, and our pharmacy in the district drives to the patient. This is because we have an MOU or Memorandum of Understanding with our pharmacy. They agree to deliver the remaining doses of NPEP to wherever the patient wishes. Whether that's their house, their work, a library, the 7-Eleven, any corner or street that they choose, or the patient has the option to pick up the medication, it's their choice. This patient was concerned that they would potentially be charged, or their insurance would be charged, and that they would receive a bill for the exam and medications. The patient was concerned that her insurance was potentially going to be charged for the cost of the exam or the entire exam and for NPEP. We assure the patient that her crime victims compensation application was approved and she would not be billed for either the exam or NPEP. Please know that she never received a bill, so that's great. As far as safety goes, it's important that we are letting the patient be aware that they will receive an explanation of benefits. An appointment was made with her primary care physician for follow-up related to NPEP and to receive that fourth-generation HIV test. So, she had done that follow-up, she had planned that follow-up visit, if you will. An education was provided to seek emergency care. So, if there are any changes to her signs and symptoms related to strangulation, such as voice changes, vision changes, difficulty breathing, maybe weakness on one side, those signs and symptoms were provided to that patient as education and encouraged her to seek emergency care if she experienced any of those. So, that's our first patient encounter. We'll move into our second patient encounter next. All right, this is the second patient encounter. Patient EE is a 24-year-old Caucasian female who presented to the emergency department status post or after a sexual assault. Dispatch reported the patient was sexually assaulted by a stranger at an unknown person's condo in the District of Columbia at approximately 3 a.m. At this time, the sexual assault unit and law enforcement were not involved with this patient, and the dispatcher notified me that the report to law enforcement was not yet initiated, but the patient was considering. And our, again, partner advocacy agency was present for this exam. As we go through this patient encounter, you'll notice a few changes to our medical forensic record. And just so you're aware, this exam took place about two years ago. Here is part of the patient's demographic information redacted to ensure privacy. But again, a place to capture their name, date of birth, their age, sex, gender identity, ethnicity, medical record number, hospital account number, and contact information. All of that information can be found there. You can also see here the general changes from our last medical forensic record. Again, it's important to update your records to ensure you're capturing proper patient demographics, including the patient's sex and their gender identity, being inclusive of their ethnicity, and the medical forensic record is just that. It's medical in nature, one that should be inclusive and patient-centered. I will tell you that this record that you're currently looking at was updated in 2017, and I will tell you another version of our record was just updated again just a few months ago. On this slide, you will see here's a portion of the medical forensic record, which is the investigative information. This includes the police report if it was filed or if the patient is considering or unknown at the time, the CCN or chief complaint number or unknown if it was unknown, the law enforcement agency involved with this patient, the investigator's name and contact information. It's important to capture this information on law enforcement as they will be the team receiving the kit and handing it over to the crime lab. I'm sure like many of you, you have multiple agencies that could be the primary agency involved. For example, was it the sexual assault unit detectives? Was it a local law enforcement agency? Maybe a neighboring state's law enforcement agency. Could be U.S. Park Police if they have jurisdiction over this exam. Maybe it's NCIS or Naval Criminal Investigation Services. Maybe it's Border Patrol or maybe FBI. Those are just a few examples, but an important reason why we're capturing that information. The patient's consent is just below this field. There's a paragraph just below the section which details consent to conduct the medical forensic exam, obtain a history and evaluation, a physical assessment and documentation of findings. So the patient signed this consent for me to conduct the entirety of the medical forensic exam and the patient also signed the consent to release information to our advocacy partners. I should also mention that the consent process is fluid. The patient can make the decision to revoke or even sign a consent at any time. And for example, maybe this patient is considering to make a report. They can sign a consent to release information to law enforcement any time frame after the exam. This is the patient's medical history. The patient reported no known drug allergies. They're not currently on medication. No medical conditions and their tetanus and hepatitis B vaccines are up to date. The one item noted on this page is that the patient endorsed that they were seen and treated by their gynecologist for a recent annual exam that was within the past 30 days. If the patient mentions this, I will follow up or clarify if they were prescribed any medications during the visit or if they had any pain or discomfort at that time. I'm just that I'm capturing this information on the chart. Following along with the medical forensic record here, you can see the patient's female specific medical history, such as the last menstrual period, any prior pregnancies, if they are currently using birth control or any form of it. So we will note that the patient has an intrauterine device or IUD and that box is checked. The patient denied hysterectomy or that they are currently pregnant. The bottom portion of this slide includes just one section of the review of systems, that being the neural section. During the neural review, the patient stated that during the time of the assault, they felt lightheaded, dizzy, that she had loss of consciousness, memory loss, and that she had difficulty forming words. The rest of the review of systems, such as cardiovascular, head, eyes, ears, nose, throat, etc. And when answering if she's experienced those symptoms or currently experiencing those symptoms, there was no response for that time for both the time of the exam as well as time of the assault. And that's a reason why I did not include it within this webinar. The patient declined having consensual sexual activity in the last three days from the time of the exam. We have since changed this question to reflect consensual sexual activities in the last five days, as we can collect evidence up to five days post assault. And saying this, please know this is very different than seeing or treating a patient if the patient presents at day seven, for example, we will still have evidence up to five days post assault. If the patient presents at day seven, for example, we will still see this patient. And with that, provide what we're able to. So we're, for example, able to provide or offer medications, provide resources, documentation of injury, and still capture this information or question. And maybe it's special circumstance that maybe that we could potentially collect evidence still, even after that five day mark, depending on the circumstance. But questions like this, we're still going to ask. So why do you think we ask about consensual sexual activity? What significance does this question represent within regards to our medical forensic record? I'll give you a second to think about that. All right, there are a few reasons. And there's a potential that we could swap for someone else's DNA. This could help with our crime lab or a crime lab would appreciate that information. But there's also a potential that injury could be encountered. So please know that you can have or find injury from consensual sexual activity, just as much as you can find injury from non consensual sexual activity. So this is the reason why we're asking this question. One for DNA and but also for any kind of potential injury. This slide represents the patient's history of present visit, their narrative of what happened during the assault. So this patient states, well, this narrative states 24 year old Caucasian female presented to the hospital with concerns of being drugged and sexually assaulted. The patient reported she is unsure of what happened, but that she woke up in someone else's house without clothes on the patient indicated that she is not sure if she had memory loss or loss of or lost consciousness. It's important here to know that I'm not a trained forensic interviewer, rather, we are capturing what happened during the assault in the patient's words. So in our program, we're not trained to provide that forensic interview. But the patient told me that she was unsure of what happened. So that is sufficient for my exam is I'm going to provide or offer every swab I have available to collect for any potential evidence for what that patient consents for me to do. The narrative guides my medical forensic head to toe exam. So if the patient is unsure of what happened, guess what, I'm going to offer everything possible. In relation to my first patient encounter where we know that that patient was orally assaulted, tied up at our office, we know that we clarified ensuring that nothing happened to her vaginally. Well, we're not going to subject that patient to a vaginal exam, because that patient knew exactly what happened. But in this case, this patient has no idea what happened. So guess what, I'm going to offer everything possible. And please know this is very dependent on the patient encounter, even the age of the patient. But in my experience, and for this specific for this specific patient encounter, I'm not asking or probing the patient for more information. I'm not saying so tell me more or so then what, as that's not being trauma informed, especially since the patient stated they did not know what happened. I may ask if they have any pain anywhere. But that might be the extent of my clarifying questions. If the patient states they are unsure or that they don't know what happened, it tells me I'm in that that tells me I'm offering as much as possible. If there's a chance that the patient recalls something that had happened, we can certainly go back and add that information into the narrative. This slide goes through the relationship status of the assailant or the subject, which was noted here as stranger. Don't be surprised. Sometimes we help our patients to understand the differences between stranger brief encounter acquaintance or family member. Just so you're aware of that. I captured the description of the incident location, which this patient stated in DC and somebody's condo. It's documented here that they didn't injure the subject in any way. This is to memory, but it's also something for example, I'm asking about to see if they or to see if I need to be sure that I'm collecting fingernail scrapings or fingernail swabbing. Maybe for that potential scratching or defense injury. The patient stated no to my question of being threatened or injured with a weapon. The last item on this slide asked about voluntary use of drugs or alcohol around the time of the incident, which this patient disclosed, yes, I had been drinking a few hours before that. It was five drinks between 8 p.m. and 1 a.m. It was gin or vodka. When I'm asking if they voluntarily had anything to drink or if they voluntarily use drugs, it's important to talk this question through with the patient. I'm not asking them to get them into trouble or share that information with law enforcement. This is for my medical forensic exam and for the toxicologist when I collect blood and urine for a potential drug facilitated sexual assault. This slide shows for the contact matrix, which is slightly different from the first patient encounter that you guys that we went through today. But you can see here the patient was unsure about vaginal, digital, or penile, anal, or oral contact. So it was unsure throughout. And again, this is based on what the patient endorses, not something I'm guessing for them or fighting to get out of them. If they provide further description, that information is captured within these description boxes as well. Here are a few safety screening questions that we ask all of our patients. This is a recent addition to our medical forensic chart, recent as in the end of 2017. And the importance here is that we are screening 100% of our patients to truly identify trafficked patients and be able to provide the best resources for them. These are the questions we ask the patient. Again, not answer or guess for them. If they have clarifying questions, we can help walk them through the questions, maybe change how I'm asking just slightly so that they can understand or grasp the question altogether. And for some of these questions, it's important to get down to the root of them. So for example, living in a location that's controlled by someone else in charge. Well, if the individual is living on campus in dorms, that would not necessarily constitute a yes response here, right? So this is what I mean by ensuring the patient understands what is being asked. And a small side note, I had one patient say thank you for asking these questions and screening her. She knew that she was not trafficked but felt the questions are important for every one of our patients as she received human trafficking training at her place of employment, which happened to be a major hotel company for those who are wondering. But we'll move on. All right, for our medical forensic record, here are our DFSA screening questions. If the patient states yes to two or more of these questions, we consider collecting blood and urine for toxicology testing. There are a few scenarios that come into play than just answering yes or no to these questions. But again, this is patient by patient. All right, so we collect blood up to 24 hours post-assault and urine up to 96 hours. Urine is the time capsule here for toxicology testing. And this is different from someone who is, for example, held captive, assaulted over a period of time, and forced drugs or alcohol over that period of time. But that's just one example of why we would maybe extend our boundaries for these screening questions. This patient stated yes, they are concerned for being drugged without their knowledge, experienced nausea and vomiting, concerned for loss of memory or lapse of consciousness, and indicated yes to voluntary use of drugs and alcohol. The last question is, on the slide, asked about their knowledge, if they knew of the location of their last ingestion. We even asked about the location of their last memory. I will mention that Section C, Chapter 7 of the Adult Adolescent National Protocol for Sexual Assault Medical Forensic Exams covers alcohol and drug-facilitated sexual assault and goes further into depth. But following protocol, I collected a cup of urine, a full cup of urine, in a clean plastic container. The sample was not a clean catch. Again, not a clean catch. As one, bacteria does not compromise test results. And two, if that patient wiped prior or even used toilet paper after they used the restroom, that could potentially lose our evidence, right? So we have to refrain from having them wipe. Also, with urine and any evidence, we must maintain proper chain of custody. This urine cannot be poured into another container and handed over to the hospital lab for a urine pregnancy test. Those should be completely separate samples that are collected. With this patient's blood specimens, I collected her blood in the glass gray top tubes, three of them to be exact. And a blood alcohol level was obtained during this exam. That was separate from the gray glass top tubes. That blood alcohol level was sent to the hospital lab for analysis. The other labs were sent to our toxicologists. I will also mention that the National Best Practices for Sexual Assault Kids also covers toxicology blood and urine specimens, including proper specimen handling and storage. Here are the patient's vital signs. Nothing too crazy, right? The patient is awake, alert, oriented, calm, cooperative, and answering questions. The patient arrived in street clothes, appropriate for the weather. I wanted to add it's important to capture and document this information truthfully and honestly. If the patient was tearful throughout the exam, I would have documented that or tearful during the patient history of the assault or tearful during the head to toe exam and just wherever that information would be captured. I would not document that the patient is sad or upset because then that is my opinion and tearful isn't factual and it paints the actual picture. Based on this patient's narrative, remember the patient was unsure of what happened. Based on this information, what kind of injuries or findings would you anticipate finding? Again, let's go back to our mnemonic helpful device. How about bruising, abrasions, lacerations, discoloration, swelling, tenderness, erythema, or petechiae, pain, pattern injury? Again, bald step. There are many times that a patient presents to our exam space and we do not encounter any findings or any injuries, so how about no findings? Again, it's important to recognize that this does not mean that an assault did not occur. All right, so full disclosure, photos will commence on the next slide and there will be an anogenital photo displayed in a few slides. Something to consider or think about for those that are in the same room as you or maybe eyes or ears in the room that's with you watching this presentation today. How would you document the findings in this photo? What are you seeing? I'm going to pretend that I heard abrasions. That's wonderful. Perfect. How about redness? Yes, absolutely. And swelling. Great job. Absolutely. I would want to see what's going on underneath that lip too, right? So maybe we'll see that in the upcoming photos. One comment on swelling. You can see the patient's lip swelling with just that one photo on the top left, but with swelling, and because we know that photos are only one dimensional, we have to move around our patient to capture different angles to truly capture that depth of that swelling. There is even a linear black substance noted on the patient's right cheek. Per the patient, that's their mascara, so that's what was documented. And it did wipe off pretty easily with a swab, just so you are aware of that. Each of these findings would be captured using rule of thirds, measured, documenting the length and width, and documented with the descriptions we already mentioned. Also, please know that these injuries go beyond these photos. Again, I wanted to crop the photo to deidentify this patient as much as possible. All right. Here is finding number two and number three. Finding number two is that right upper lip abrasion. I would also look at the patient's gums and frenulum, making sure that those structures underneath are intact. And take a look at finding number three. She has a chipped right lateral incisor. In my practice, I certainly go through each tooth, asking if that tooth is loose, chipped, cracked, at the time of the assault, before the assault, or at the time of my exam. I document any findings, and for dental injuries, I recommend the patient follow up with their dentist, or if they need a referral, I offer that referral as assistance. So, finding number two and number three, that right upper lip abrasion, as well as that chipped right lateral incisor. I should tell you that it's an abrasion because it's superficial. It's that superficial rubbing or scraping away of that tissue, whereas laceration is deeper. You'll get that adipose tissue. You'll also have the tissue bridging, most likely needing a repair if it needs one, but that's the difference between abrasion and laceration. All right. So, I'm going to go ahead and move on to the next slide. So, here are a series of photos in rule of thirds. So, the top left, the farthest away, that's to capture where the injury is located on the body. So, you can see the left lateral knee there, or medial part of the knee, excuse me. The bottom left is the third closer to truly identify the injury, and then the photo on the right is with the use of an ABFO number two ruler to capture the length and width of that injury, and ABFO stands for American Board of Forensic Odontologists. It's just a true to scale measure or ruler. So, finding number four would be documented as a circular brown bruise to the medial aspect of the left knee, one inch by one inch in size. If the patient endorsed any pain or tenderness, I would absolutely document that as another finding. So, that's number four, a circular brown bruise. Looking at this photo, what are you seeing and how would you document this? So, what's going on? Think about colors, fluids, consistency, abnormal and normal variances, foreign objects, anything you can see there. And I say foreign objects because there could be a number of things found, such as hair, tampons, condoms, etc. It's important to note that this here is not a foreign object, and it's important to highlight that this is the patient's, you said it correct, IUD string. Good job. If you recall during the medical history taking, the patient reported an IUD. As nurses, we only swab this area, never pull or tweeze that string from that patient. If so, we're going to introduce further injury or harm, not to mention the further resources at this time to have it replaced. So, identify the IUD string, swab the area and nothing else. Findings here were documented within the medical forensic record as thick white fluid noted to the cervix and vaginal vault. The IUD string was noted at nine o'clock from the cervical os. This photo was from the very first view. My next photo was of the cervix after I cleared it off with that Fox swab. Unfortunately, I did not include those photos within this presentation. On a small side note, and thinking about the flow of my exam, so the external genitalia swabs, the perineum swabs, they were collected prior to the introduction of this speculum. Traction and separation to the external genitalia was applied. The posterior fachette and fossa navicularis was assessed. Hymenal tracing was conducted and assessed as well as teludine blue dye that was applied, removed, and assessed, again, prior to introducing this speculum. And another small side note, so cervical photos or vaginal photos in general can be tough to capture until you get the hang of it. So think about the lighting of the area or the room you're in, the lighting of the room, the light source on that speculum, fluid that's within the vaginal vault and around the cervix. These are all important things to consider or be aware of when taking your vaginal cervical photos. Also, we don't want to have this patient in this position or lymphotomy position with the speculum for extended length of time because they're maybe not going to tolerate it. So the next slide is going to be an image of the rectum with the use of an anoscope. So how would we document the finding in this photo? Are there any findings? And it's important to know that perianal swabs were collected and teludine blue dye was applied, removed, and findings assessed prior to introducing this anoscope. The perianal area did not have any uptake with the TB dye. And before going on, I should also mention that when teludine blue dye is applied to the perianal area or any area for that matter, it should be applied to that specific area, left in place for 60 seconds, and then wiped away with gel or gauze or 1% acetic acid spray. All right, moving on. Were there any findings? What do you think? I will say that this is a good-looking rectum. It's pinkish, blushy in color. There are no abrasions, tears, or blemishes. There are no abrasions, tears, or lacerations that I could see with my naked eye. But, and there's always a but, right? After swabbing this patient's rectum for evidence, I noted the swabs had a scant volume of blood noted, which was noted in the medical forensic record. I'm also gonna mention that an anoscope is a tool to help visualize the patient's rectum to identify any injury and swab for any potential evidence. There is an obturator that is used to help guide through the anus into the rectum, and then you can remove it to get this visual. I will also say that not every program is using an anoscope, and it is definitely a clinical skill that you should be checked off on before you're actually using one. This slide covers the evidence that was collected for the PERC, or Physical Evidence Recovery Kit. The items collected included lips, oral, breast, nipple, thigh, external genitalia, perineum, vaginal, cervical, perianal, anal rectal swabs, and the patient's known blood sample, which was a fingerprint. If the SBAR did not include a rationale to why I did not collect the patient's underwear, either worn at the time of the assault or after, I would certainly question that in the peer review process. It's important to mention here that when a patient is unsure of what happened and they were concerned for being drugged, for our patients in the D.C. area, we usually always see a positive hit from that breast and nipple swab. So just maybe something to think about. Here's the provider summary. So the situation, the 24-year-old Caucasian woman presented to the emergency department with concerns for being sexually assaulted and drugged. The background is the patient requested a forensic nurse examiner to conduct a medical forensic exam. The assessment included that they were A and O times three or alert and oriented times three. Their airway, breathing, and circulation was intact and speech was clear. The head-to-toe exam was completed, and findings included abrasions and redness with swelling to the face. See the medical forensic record for exact location and more information. A chipped right lateral incisor. Circular brown bruise to the medial lower extremity. Thick white fluid to the vaginal, vault, and cervix during speculum exam and lithotomy position. The IUD string visualized to the cerviclaws in the anoscopic exam was completed with blood noted to the swabs. Recommendations included the MD was aware of the exam and findings. PERC was completed. Specimens were collected for toxicology testing. Medications were administered by the primary nurse. Patient verbally stated she understood side effects of medications and rationale for taking them. The plan is to follow up with her primary care physician for follow-up blood testing. And she stated she feels comfortable going to her house. Again, here are some items that are important to cover during the discharge process, which we covered during the first patient encounter. But again, patient education, answering any questions they may have, making sure that they're understanding everything that happened during your exam today. Medications that were provided, side effects of those medications, medications that they're going to go home with and a rationale for why they're taking them home. Medications that are provided by the primary nurse. Medications that are provided by the pharmacy. Have that follow-up discussion related to STI, HIV, and pregnancy testing. Ensuring they're aware of their advocates and how to get ahold of them. Law enforcement and how to get in touch with them. Information on their kit tracking database and where their kit is in within the system. Follow-up discussion related to payment for the exam. Answering any questions they have. Regarding payment or how they can complete that crime victims compensation application. Notifying the patient that the program will call and follow up with them in a few days time and ask them any questions that they, or answer any questions they may have. Last but certainly not least, we must ensure every single question the patient may have is addressed before they leave our exam space. So again, this is the DC crime victims compensation application, which was completed inside by this patient. The form was submitted and because of this, the patient did not have to pay over the $3,500 for their 28 days supply of NPEP. This patient was eligible for crime victims compensation in the district because she simply fulfilled the requirement of having the medical forensic exam. Whether she was reporting to police or not, she was not eligible for the NPEP. She had the exam, so she does not need to, this is the reason why she's eligible for CDC. Here are the patient's toxicology results, which we received just about one month after the office of chief medical examiners toxicology lab received them. Each patient with toxicology results are documented within the patient's electronic medical record, along with a saved PDF version of their tox report. Please know that the report includes a greater depth of information such as volume, which substance was found in their, either in their blood, urine or both. It's important to note that at the time of the exam, this patient had not connected with our sexual assault unit detectives, but our program will send patients, will send a patient's blood and urine for toxicology testing, whether they report to police or not. And of course with their consent. So our practice is to call every patient and notify them of their toxicology results. This patient's results showed for caffeine, which we probably find in everybody. And the patient's results also showed for quinidine and quinine. Does anyone know why that would show up within this patient's blood and urine? So what is quinidine and quinine? So quinidine and quinine was once used to treat uncomplicated malaria, but it's unlikely that our patients are taking this for these reasons, right? Quinine can be found in tonic water. So think about it. If you've ever worked at a bar or restaurant, you know the tonic button is on that same soda nozzle as all the other drinks. Well, all sodas are coming from that same nozzle. If the patient had a mixed drink or even a soda, there is a chance that they had the same tonic water mixed in, which would produce these results. And if you can remember, the patient stated she voluntarily drank either gin or vodka, five drinks between 8 p.m. and 1 a.m. And there might've been a chance that she had a gin or vodka and tonic. So something to think about there. Before moving on, I just wanted to say that we recently conducted a few webinars on interpreting toxicology and drug-facilitated sexual assaults. And those webinars are a two-part series and it can be found on IFN's online learning center. From those webinars, we know that any kind of date rape drug metabolizes so quickly that it's rare to capture. Plus there are so many factors that go into capturing a true date rape drug, such as metabolism, when the patient was potentially drugged to when the blood and urine was collected, the volume consumed, their activities of daily living, such as drinking, eating, peeing, pooping, et cetera. So please go watch those webinars if you have the chance to do so. Here are a few resources. And if you haven't already, please visit safeta.org. It's that last bullet on the slide. This website houses plenty of documents, tools, protocols, including documents about payment for the medical forensic exam. You can find webinars housed on this website, tons of great information. After your exam, your shift or your day, make sure you're taking time for self-care. Whether this is 10 to 20 minutes to yourself, grabbing your favorite coffee, maybe reading a chapter in the book that you're reading, maybe going for a walk, clearing your mind, anything to give you time to yourself and help balance your emotional and mental health. All healthcare providers, or as healthcare providers, we must make sure that our mind and our body are balanced so we can provide effective care to our patients, preventing vicarious trauma and or burnout. So I know we've covered two patients today. It's like seeing two patients or encountering two patients. So I encourage you to practice self-care after this webinar today.

webinar

medical forensic chart

patient photos

Nicole Stallman

forensic nursing

sexual assault

documentation

assessment techniques

evidence collection

patient care

injuries

follow-up testing

forensic nursing specialist

medical forensic examinations

trauma-informed care

patient-centered approaches

National Best Practices for Sexual Assault kits

Crime Victims Compensation

self-care for healthcare providers