Thank you so much, Mary-Kate, and thanks to the National Council on Juvenile and Family Court Judges for hosting us today, and of course, the Office on Violence Against Women for making this possible. I'm Jessica Midland with the Victim Rights Law Center, and I'm just so delighted and honored to be able to host today's webinar for all of you. I'm joined by Angelita Olowu and Susan Chaston, both of whom, well, Angelita is with the International Association of Forensic Nurses, and Susan is with the Utah Coalition Against Sexual Assault. I will let each of them introduce themselves when we get to that, but as the National Director of Training and Technical Assistance for the Victim Rights Law Center, I'm just so happy that all of you are here and are able to join us today. I wasn't sure whether Mary-Kate mentioned this, but I do want you to know that today's webinar is being recorded, but the chat does get stripped out before that recording is shared. Angelita, next slide. And this will be in your written copy as well. We are sending out the PowerPoint afterwards to everyone who registered for the webinar, so if you have any questions about it, we always just like to let people know, first of all, that there are no conflicts in terms of conflict of interest in this presentation today, and that if you do need credit to contact the IAFN following that, excuse me, to request that. And next slide. This webinar, I just want to note, is actually part of an ongoing series that we're hosting. There'll be some information at the end of this webinar, and we'll also be following up by email just to share the information with you that we have a number of upcoming webinars. We have a whole series that we will be hosting next month specific to serving youth, to serving minors, one on legal services and advocacy for minors who identify as LGBTQ, another on minors and intersectionality issues and Black, Indigenous, and youth of color, and then a third on providing legal services and advocacy to minors with disabilities. So those are just a few. We have a lot of new resources coming out, and if you are interested in any of that information, please contact us at TA, or Technical Assistance, abbreviation is TA at VictimRights.org, and victim is singular, rights are plural. Next slide, please. I just want to briefly, before turning it over to Angelita and to Susan, let you know that while you're seeing me today, only for a few more moments, I'm going to shut off my video in just a moment or two, but I'm part of a wonderful team that supports the work of the Victim Rights Law Center in helping all of you in the work that you do on behalf of and funded by the Office on Violence Against Women, and that we provide our technical assistance in many different formats, whether it's individual case or programmatic advice, we host a number of trainings with wonderful guest expert speakers like today, and then also that we deliver directly. We are here to mentor, especially lawyers who are new to practicing law and or new to representing sexual assault survivors. We have a very comprehensive privacy technical assistance project, and we're often asked to help folks navigate as victim service providers, complying with their vowel confidentiality and other obligations, reviewing policies. We have a number of national surveys. So for example, we're just in the process of finalizing what each of the states and territories do with respect to parental rights regarding termination and also adoption when rape results in pregnancy. We have our privacy cards that answer a whole set of laws for every jurisdiction, one for adults, and soon we'll be coming out with our minor specific version, our clergy FAQs, tons and tons of research that we provide. So if you need any assistance, please just reach out to us again, it's TA at victimrights.org. Victim is singular, rights are plural, one victim, many rights, and these are just a few of my colleagues pictured here. Not even everyone is on here, some people prefer not to be pictured, but who are part of our TA or technical assistance team to support you. So I hope you'll reach out for help. Next slide, please. And just again, we will be sending out, there's a VRLC resource request form for OVW grantees. I will be sharing that with all of you in case you want to follow up and request any of the resources that I've just mentioned, tip sheets, guides, videos. We are increasingly translating many of our documents into Hindi, Spanish, French, Brazilian, Portuguese, Vietnamese, Hmong, so there are many multilingual resources as well. So reach out if you need any help either today or afterwards. And I mentioned some of these already, this is the upcoming series on representing, excuse me, sexual assault who are minors, and again, this will be in the PowerPoint that is provided to you. And if you registered for this webinar directly with your email address, you'll be getting that information sent to you. And that's me. So I'll be turning off my video, but here's a picture. And I'm so happy and delighted, like I said, to be able to introduce today both Angelita Aloa and Susan Jackson. And I'm going to let Susan and Angelita introduce themselves. But before I do that, I just wanted to tell you as a TA provider, they are just both incredibly helpful and knowledgeable and true experts in their field and always willing to answer questions and just to help all of us improve the work and the services that we are providing to survivors. I'm going to turn it over to you, Angelita and Susan. Thanks, Jessie. So my name is Angelita Aloa, as Jessie has already stated. I am one of the forensic nurse specialists with the International Association of Forensic Nurses. I'm also one of the technical assistance providers. At the end of the webinar, there will be a slide to let you know how you can contact IAFN if you do have a technical assistance need or a question. And we have multiple forensic nurses on staff that are here and willing to assist you. Susan? I'm Susan Jackson. I'm the statewide SANE program manager for the Utah Coalition Against Sexual Assault. And I want to thank both the Victim Rights Law Center and the National Council of Juvenile and Family Court Judges for helping us do this today. We couldn't do it without them. And yes, if you have questions, especially about rural programs or anything that you have interest of, feel free to reach out when this is done. So we're going to go ahead and get started with a poll question. And we want you to answer whether or not you have already worked, had an opportunity to work with sexual assault nurse examiners. And we're just going to take a minute to see what your responses are. There is a poll site in the chat. You folks are really good at answering things quickly. Susan, I love the fact that it says hosts and panelists cannot vote. So that's what happens at the ballot box. Well, I really wanna welcome the people who've never worked with a sexual assault nurse examiner before. And hopefully those of you who already have will also learn how to improve that relationship, but also this will give you an opportunity to think about different ways that you might use sexual assault nurse examiners in your practice. Let's go ahead and close the poll. So what is a SANE or a sexual assault nurse examiner? And we tell our nurses, they need to be very careful when they walk into a room and say, I'm a SANE because often a patient will think, I'm not crazy, why do I need someone who's SANE? So we typically try to explain the acronym, which is sexual assault nurse examiner. And we are registered nurses who have completed additional education and training to provide comprehensive healthcare to survivors of sexual assault. And we very much see ourselves as healthcare providers. Next slide. Having said that, depending on where you are, people may be doing the work of a SANE, but have a different title. Many sexual assault nurse examiner programs are now expanding out and providing other forensic nursing services, such as evaluating survivors of domestic violence, child abuse, and in that role, they may define themselves as an FNE, a forensic nurse examiner. We welcome our colleagues to be part of this work. So both physicians, physicians assistants, and in that setting, we may be called a SAFE, a sexual assault forensic examiner, because that leaves the nurse out, or just sexual assault examiner. And then the military has its own title, which is sexual assault medical forensic examiner. So the titles are different, but the role is the same. And that is to provide comprehensive healthcare to survivors of sexual assault. Next slide. So getting to know your SANE, and I think it's important that you know about the SANE programs in your state, and how one of the ways you can do that is by reaching out to find out if you have a statewide sexual assault nurse examiner coordinator. They are often housed in the coalition, statewide coalition. They may be housed in the attorney general's office, but it's important to reach out. And if you don't know, you can reach out to Angelita or someone at IFN, and they keep a list of where the sexual assault nurse examiner program coordinators are located. These are nurses who, or sometimes they're not nurses, but who are aware of where all the programs are and what the standards of those programs are. The other thing you might want to know is are there SANEs who are considered experts in specific areas of testimony? And that can include things like strangulation, why a survivor might have delayed reporting, or issues like why do survivors typically have responses that we don't feel are normal after a sexual assault? So what is the immediate emotional response of a patient after sexual assault? If you're given the opportunity to work with a SANE, what you want to do at that point is ask for their CV or their resume, and you want to sit down and review it with the SANE. You're going to find that you have a variety of expertise in the sexual assault nurse examiners in your program. In Utah, we just trained an entire new batch. Their experience is going to be very different from our nurses who've been doing this, now some of them for 20 years. So you want to sit down with them and go over their CV, because even though they may not have a lot of experience as a sexual assault nurse examiner, they have a lot of nursing experience. They may have been an emergency room nurse or a labor and delivery nurse for many years, and it's that nursing experience that you want to be aware of when you're trying to establish their expertise as someone who can identify injury or somebody who can talk about patient care. Next slide. The other thing you want to know is what have they, what kind of education have they completed in order to become a SANE? And I think Angelita is going to take over from here. Yes, Susan, thank you. Should have chimed in. I got behind on my numbers. That's okay. So yeah, you want to know exactly what education have they obtained. So have they completed their 40-hour SANE training that's required for them to actually be practicing as a SANE nurse? You want to actually verify that they have completed that SANE training, and you want to know how long ago did that occur. Find out if they are certified as a SANE-A or a SANE-P, or do they have both certification? You also want to know if they have a state-specific certification requirement. It is important for us to understand that there's a small amount of states, there's actually eight of them, that actually require the nurses to have specific education before they, before that particular state will allow them to practice independently. So it's really important to know that if you live, to know if you are practicing in a state that has that requirement, and verifying that for these nurses before you have them testify or as part of their testimony. So let's take a few minutes to discuss exactly what it means to hold a SANE-A or a SANE-P certification. So the SANE-A or SANE-P are two professional credentials that designate that the nurses achieve the highest standard of sexual assault nurse examiners. And what it does is that they have to, they have to meet specific requirements, which include that 40-hour didactic SANE course for adult adolescent, for adult adolescent, and for 40-hour didactic course for the pediatric if they are holding a SANE-P credential. They also have to complete their clinical education and preceptorship. And then they also have to have practice a minimum of 300 hours during the last three years. They have to have taken and passed the national certification test. And then after they receive their initial certification, the nurses have to have a specific amount of continued education that falls in between this three-year time period in order for them to be able to renew their certification. I just wanna also go back and reiterate that the SANE-A and SANE-P certification is not required for the SANE to practice as a SANE, okay? So again, the SANE-A, SANE-P is totally separate from that state-specific requirement, and nurses do not have to hold that SANE-A, SANE-P to practice. So for example, in Susan State in Utah, there are 140 SANEs, and out of those 140 SANEs, only seven of those nurses actually hold a SANE-A certification. And Angelita, I like to explain in terms that most people understand. The 40-hour course is kind of like taking CPR. It's the basic thing you have to have before you can practice. But anybody who takes CPR knows that pretty much they take the class, they practice, they get their CPR card. That is not true for the certifications. The certification is more like something, the emergency room nurses have a certified emergency room nurse. And if you walk into your emergency room today and ask your nurse, is she CEN certified? Chances are she's gonna say no, because that's just a higher level of recognition, and you really don't have to have that to practice in an emergency room. Correct. It's kind of showing your expertise in your field. Absolutely. So I have another poll question for you. This is a true or false question. There's no way to verify if a SANE holds a valid nursing license or a certification. Is that true or false? Your poll question should pop up on your screen for you. And Angelita, while we're waiting for folks to vote, I found it so helpful for you to sort of summarize and review what the qualifications are. Because in my head, of course, I was immediately sort of thinking about qualifying your witness as an expert witness, and the kind of credibility that it lends to their testimony when it comes to their certification. The credibility that it lends to their testimony when you have folks who have just accomplished so much training in addition to the underlying foundational skills. Yeah, that is really important. And that's also why it's so important for you to actually take the time to have conversation with that SANE and to learn about what they have done, how long they've been in practice, what their experience is, the types and the amount of cases that they have worked through. All right, so we can close the poll down. So 98% of you said false, and that is correct. We wanna believe that the SANE has telling us the truth, but you also wanna make sure that you're actually verifying that the information that you're receiving is actually accurate. So you can verify the nursing license for the nurse that you're working with through the National Council of State Boards of Nursing. And you can also verify that they have their SANE-A certification or their SANE-P certification through the IAFN. You also have the ability to verify if they have that state-specific certification. So again, it's recognizing if you are actually in a state that has the state-specific certification, there's only eight states out of the 50, and then looking to see where you will find that information. So in the chat, Susan is going to add a link in there. The IAFN has a SAFE-TA project, and on there, we have a website called SAFE-TA.org. There is a resource that you can use too. It's a clickable. You can click on your state, and it'll tell you on there if your state is one of the states that requires the state-specific certification. And so from there, you can kind of look to try and see where you would verify if there's a current state certification for that nurse or not. And I have put that link in the chat. Thank you, Susan. It's important to understand the foundation of nursing practice and the legal foundation for that nursing practice because the role of the nurse is very different from the other people that are typically involved in the care of the sexual assault patient. It's very different from law enforcement. It's very different from the prosecutors. And the foundation of our practice is our Nurse Practice Act. Every state has a Nurse Practice Act and has nursing rules and regulations. And if a nurse wants to keep their license, this is what they have to follow. So while a police officer may be able to do something to a suspect, a nurse may not be able to do that same thing without following the rules of the Nurse Practice Act. But nurses are also required to follow federal law, and the two big ones that are typically important to this type of practice are HIPAA, which is the Health Insurance Portability and Accountability Act, and EMTALA, which is the Emergency Medical Treatment and Active Labor Act. And why these two federal laws are important, you may want the same nurse to share the patient's information with you. And if they're giving you pushback, it's probably because of HIPAA. They have to follow regulations in order to not be in violation of HIPAA, to not violate their patient's privacy. There's probably also aspects of the Nurse Practice Act that requires them to keep patient information confidential. There are exceptions to HIPAA, but the biggest exception to HIPAA is that if you have a client and you need a copy of their medical records, if you get written consent from the patient to have the nurse release those records, then HIPAA isn't involved. If the patient wants you to have a copy of those records and you can get a written release of records to give to the nurse, that is an easy way to solve that problem. EMTALA means that patients that come to the emergency room have to get a medical screening exam and have to be determined whether or not they have an emergency medical condition and needs to be treated right away. And that law is triggered even if you walk onto the campus with an emergency medical situation, you don't actually have to walk into the emergency room. But the nurses need to understand the federal laws and their state laws that surround their nursing practice. And they should be able to articulate those laws to you if you're asking them to do something that's in violation of those laws. Next slide. The other thing that nurses have to be aware of and impact their practice are the mandatory reporting laws. Pretty much every state in the union has a mandatory child abuse reporting law that applies to nurses. There may be elder or vulnerable adult reporting laws. There may be mandatory reporting laws that come to infectious diseases, meaning gonorrhea, chlamydia, HIV may have to be reported. And what these laws are saying is you have a duty of confidentiality to your patient, but this law orders you to break that, to breach that duty. The other thing is hospitals and agencies can create their own policies. So for example, in Utah, our policy is that we will not provide an exam to an unconscious patient unless that patient meets certain circumstances. So the law, the hospital and agency policies have to be in compliance with federal law and the Nurse Practice Act, but they can actually be even more strict if the hospital feels like that's the best way to protect the interest of both patients and nurses. And then the field of forensic nursing actually has forensic nursing scope and standards that gives us guidelines for what to do and gives us guidelines for what is within our scope of practice as a nurse. And those are important to understand both for the nurse and people working with nurses to make sure that you're not asking them to do something that's outside of their scope of practice. Jesse, I don't know if you want to chime in here, but I know that the Victim Rights Law Center has multiple resources around mandatory reporting. I don't know if you want to mention some of those here. Sure, thanks Angelita. We have lots of resources on mandatory reporting. We have several flow charts that we have created primarily for OVW grantees on child abuse, mandatory reporting on abuse of older survivors or actually older individuals or individuals with disabilities. We have kind of worksheets designed for providers to fill out to kind of identify to whom are they making referrals and also who is within their own organization or institution who is and is not a mandatory reporter and what are they mandated to report. We of course address this in our minor specific FAQ jurisdiction specific cards that will be coming out very, very soon. They've been OVW approved for just doing the final formatting touches on those. And then also, as I noted in the chat that we're finalizing a document that just sets out some of the differences between HIPAA, VAWA, confidentiality, VOCA and FERPA which applies to educational institutions. So if you are having some challenges around mandatory reporting or navigating what may or may not or must or must not be disclosed, feel free to reach out on that. Obviously we can't give legal advice. We're not licensed to practice law in your jurisdiction or if you're not our client, which you wouldn't be but we have just tons of resources and we're always happy to help folks just think it through and navigate what sometimes looks very straightforward but in fact, in reality can be quite complex. And I see that there's a question in the chat box about asking for a link for the resources. Everyone will get the VRLC resource request form that you saw pictured in the slide at the beginning and that will be the place because also if you want jurisdiction specific resources we'll ask you in what jurisdiction, what state or tribe or territory. There was also a statement put in the chat box about EMTALA only applying if you are a ER based program. I think that's something you need. If you are hospital based, I think that's something you need to discuss with your hospital legal counsel to find out when EMTALA is triggered. If you are only community based, it may not apply to you but it may apply to you if patients are arriving at emergency departments and they need to figure out how to get them to your community based program and not violate EMTALA. So that's something that you should always discuss with your hospital legal resources before you make a determination about something like that. Next slide. So there are two legal concepts that apply to SANEs. One is informed consent. And we are very adamant about the fact that we don't perform medical forensic exams on patients unless we have their consent and their informed consent. And while patients give us consent at the beginning, usually written form at the beginning of an exam, we let the patients know that that consent can be withdrawn at any time and that they are not consenting to the entire exam if at some point during the exam, they want to decline to have a test or procedure or information done, that's not a problem. The other thing is that we've already talked about is confidentiality. Now, the problem with confidentiality is when patients are coming to us for a medical forensic exam, typically we're gonna be sharing their information with law enforcement and prosecutors and victim advocates. And so as part of that confidentiality, we get written authorization in order to share that information. And we also tell them what the limitations of confidentiality is. We typically work with community-based victim advocates who have a different level of confidentiality with patients. And one of the things that we need to make clear at the beginning of the exam is what those levels of confidentiality are and who has the ability to maintain confidentiality, what the patient is saying. So let's talk a little bit about the medical record itself. So you definitely wanna consider if your state has a specific standard form or not. But as you're thinking about that, please understand that there are plenty of states that actually do not. So you may be in a state that has a standard form, but there are many states that do not. But what we wanna point out is that there's some specific information that should be there regardless of your state. So if you're in a state that has a standard form, there's some information that should be there regardless if there's a standard form or not. So some of the things that are typically covered would be the medical history of the patient. So this would include any medications that the patient is on, whether that's over-the-counter or whether they are taking something that wasn't actually prescribed to them. Do they have any chronic illnesses? I definitely have information on the obstetrical history and then any surgical history that the patient has had. It should include the history of the assault, and then also the demeanor of the patient throughout the whole examination. And I think, again, the reason we're getting all of this information is we are providing healthcare, and these are the types of questions that we're gonna ask every patient. So when you're thinking about what you have in front of you, you wanna try and look a little bit more thinking about what can the SANE actually educate in your courtroom about. So, of course, they can educate on information from the actual exam itself. So, again, specifically going into details about medications and how that medication may or may not have affected how the patient presented or any findings that came across from the patient during the examination. Chronic illnesses, does that patient have any chronic illnesses? Again, do these illnesses possibly contribute to some of the findings that we're seeing with the patient? Factors that may explain the presence of any injury or any evidence, but also the absence of any injury or evidence. That's really important to be able to comfortably explain that. What statements did the patient make that showed that there was a lack of consent during the actual assault? And then did the patient have any statements that acknowledged that there was some fear or some concern for their life or their safety during that time or even during the time in the exam with you? Those are really important things to cover. Another thing to just think about when I talked about injury, the SANE could also be able to explain to you the healing process of injury. So we talk about the presence of or the absence of, you know, talk about, have them explain how the healing process goes for injuries. Additionally, they can explain to you information specifically regarding the exam. So they can talk about the demeanor of the patient and how it changed or did not change throughout the time that they were with that patient. They can go into presence of injury, what they seen, explain, you know, explain to the courtroom exactly what they were seeing. If there are pictures available, that's fine. If there are not pictures available, that's totally fine as well because they have the actual documentation there. They can explain the condition of the clothing that the patient was wearing, regardless if the clothing was collected or not. Same thing again, if pictures were taken, they have the ability to take a picture of that. If they're not taking pictures of that, they can document it and they have that to be able to refer back to from their charting. Whether the presence of any foreign objects or materials that were found in the examination, whether found internally or externally, all of those things are part of that documentation and they can explain what they saw, where they found it, and did the patient have any explanation to go along with that as to what they remember occurring. Angelita, the story I like to tell is I had a 14-year-old who had sexual contact with a 20-year-old, which is illegal in Utah, and while doing her exam, there were little black fuzz balls on her bottom. And I asked her what they were and she said, oh, we had sex on a black fuzzy blanket. So now I have been able to collect debris that indicates that she was undressed on a black fuzzy blanket that happened to be in the apartment of the suspect. So those are the reasons why we're looking at those kinds of things and able to then tell a bigger picture of what we saw with the medical exam to explain that to the jury and to explain the importance of that evidence. That was a great example, Susan. Thank you. You're up. So some of the topics that the SANE can cover in testimony to educate the courtroom. And we feel that this is an important process because as nurses, we are talking about genitalia and injuries all the time, but the typical juror may not have that same level of familiarity. So one of the things that we can go over in detail is genital anatomy and physiology. And typically we do that by using a drawing diagram to point out to the jury what the structures are, where they're located. And then, in addition, then use that diagram to demonstrate where we saw injury. We can explain mechanisms of injury because we know certain types of injury are caused by certain mechanisms, meaning a bruise is caused by blunt force trauma to tissue where there's then bleeding and swelling under the tissue. Or a laceration is caused by blunt force injury that causes stretching and tearing of that tissue. So we're very well prepared to explain what an injury is, how it's caused. And then because we've received a history from the patient, we can then relate that back to the patient's history. As Angelita already said, we can talk about the process of healing. Now we can't with any certainty tell when an injury occurred because the studies just don't point that out. I know when I was in nursing school 100 years ago, we were taught that a bruise that was this color was so many days old. And actually, thanks to the research being done by sexual assault nurse examiners and forensic nurses, we now know that the new research is telling us that bruises can be different colors at different times, and we cannot use the color of a bruise to pin down when an injury occurred. We can explain the process of the examination, which I think is important for juries to hear, that this isn't just a five-minute in-and-out exam. We do a detailed history. We do a detailed head-to-toe exam examining every surface of the body. We do a detailed genital exam. And I think it's important for the jury to know what the patient has experienced in order to get this medical forensic exam. We can then explain some of the examination techniques and tools. Some of the things that can be used during an exam are alternative light sources, and these are lights of different bands of light that can sometimes highlight either substances on the body or may be used to enhance the ability to see bruises. We also use something called telluidine blue dye, which is a nuclear cell dye that we use to be able to increase the ability to see injury on skin. We can also talk about factors that increase or decrease the likelihood of having an injury. And the field of forensic nursing is fairly recent. The International Association of Forensic Nurses has only been around since 1993, and we've really only been doing a lot of research in the field of injuries for a short period of time. And so we are now having multiple studies that look at the different factors that impact injury or lack of injury. And so the sexual assault nurse examiner should be able to speak to that research. They should be able to speak to the fact of what percentage of patients are likely to have injury based on the studies that have been done and also what kinds of things might increase injury. So for instance, lack of estrogen, meaning a postmenopausal woman, estrogen is the hormone that provides elasticity to the vaginal area. Lack of that hormone may be a factor for having increased injury in a sexual assault of an elderly patient. But being young and healthy and of reproductive age may decrease the fact that they're having injury. The other thing we can talk about is strangulation and the impact of strangulation. Many states have felony assault laws based on the need to prove that there was a likeliness of serious bodily harm. And our forensic nurses and our sexual assault nurse examiners can speak to why strangulation can potentially be a serious bodily harm or cause life-threatening injury. So being able to explain that to the jury is an essential part of our nursing practice. Other topics we can cover is that immediate emotional response. Because especially nurses who've had several years of experience can speak to the jury and say, in my practice experience, I can tell you that giggling during an exam is a normal response. Or I can tell you that for a teenager to text on their phone during a sexual assault exam is a normal response. And to be able to explain to the jury that these are coping mechanisms that people use during times of stress. We can also explain about our experience with delayed reporting. And that the majority of patients nationally never report. But we can explain why patients don't immediately report a sexual assault. But there are a lot of other factors that impact that decision on whether or not to report. And then also the impact of trauma on behavior. And this is something, again, we've learned in the last 20 years. And the best example I can give is I now have two adult sons. But when they were a lot smaller, if I came home from work and something was broken in the living room, and I asked them, how did the lamp get broken? And I watched them kind of look up at the ceiling, hem and haw, and then come up with an answer. I'm going to assume they're making something up. But we now know with the impact of trauma on the brain that when we ask our patients a question during the medical forensic exam, and they look up at the ceiling, and they are trying to come up with an answer, that that is the result of trauma making it difficult to recall some of the details of the assault. And they're not lying. They're not making something up. They are dealing with the impact of the hormones that occur when there's a significant traumatic event. And so being able to explain that to the jury can often be important. If, for instance, the patient tells me one part of the assault and law enforcement another, that doesn't mean that they're making things up or that they're conflicting on purpose. It may mean it's the impact of trauma. So this is my favorite part. What can a saying not tell a courtroom? I can't tell you whether injuries were the result of consent or non-consensual intercourse. We have now done enough studies about injuries after intercourse, consensual and non-consensual, to know that you can have an injury with a consensual relationship. And we know that about 50% of our patients who have been sexually assaulted have no genital injury. I also can't tell them how much force was used during the assault. And in this instance, force meaning a physics term, not one where the assailant is forcing someone to do something. Because again, everyone's tissue reacts differently. And it's going to depend on a lot of factors. So I can't give you a very hard and fast opinion on this frequently. As I said earlier, the age of bruises is something we no longer talk about as far as being able to say, well, this bruise is two days old and this bruise is three days old. And interpretation of inconsistent documentation from another provider. So again, if I'm there as an expert witness and I see something, I've reviewed the photographs from the exam and I see something different from what the original examiner has documented, I may not be able to explain why they documented the way they did. I will explain that we typically give the person doing the hands-on, eyes-on exam the benefit of the doubt for what they've seen. Sometimes the photographs may not represent what was seen as well as what they actually saw. But I'm not going to be able to explain why they documented differently from me. I can only explain what I saw and what my documentation was. So Susan had mentioned earlier in this presentation about the use of research and how we are learning more and there's some research is available, specific things. So we have to spend a few minutes and talk about the use of research and testimony by the saint. If a saint is actually going to be referencing research, it is really important for the nurse to be familiar with the research that they are going to be talking about. And they also need to be comfortable at kind of explaining the strengths and the weaknesses of that research. They also should be able to have, to be prepared for her copies, to provide copies to the defense just in case they don't have it, so they have access to review it. The other thing that I want to point out is that if research is being used and maybe the defense attorney asks you a question regarding research that is not what you have in front of you or that you're not familiar with, it's just to make sure that you're okay saying that you're not familiar with that and requesting the ability to actually take time to review that research and not just make assumptions about it. Susan, did you want to add anything to that? And again, it's okay if a nurse is not aware of every piece of research that's out there. That's impossible to know everything. And it's important, as Angelita said, to be able to point out the weaknesses of the research and not to let attorneys ambush them with a single statement from a paper without taking the time to read it in context. So anything, so we're thinking about topics that could be covered by other experts instead of the same covering that would be anything that would be out of that nurse's scope of practice. So you want to be able to go to the source of the person that would be responsible for that. So an example of that would be the explanation of blood alcohol or drug toxicology results. So you would want to go to the crime lab, whether it is the pathologist or the forensic scientist, and have them to come in and explain that. That wouldn't necessarily be something that the SANE would be covering. Same thing for the results of the DNA test. That wouldn't be something that is typically in the scope of practice for the forensic nurse or that they're regularly working with. So you do want to make sure that you're aware of that and that, like Susan said earlier in the presentation, that we understand clearly what the scope is for that nurse in that state and what they're able to actually cover and who you should actually go to for that expertise to provide your expert testimony. So I want to take a minute and do a chat question. You guys would throw the answers to this in your chat. What are some of the ways that the attorney can ensure the best testimony outcomes are for the sexual assault nurse examiner? What are some ways that attorneys can work with the SANE to get the best testimony that they are able? We'll give you a few minutes to ponder on that and put some information in the chat. So the first couple of answers put in the chat look like meet with the SANE before testimony, pre-child prep. Oh, they're coming in really fast. Talk about documentation with the SANE. Provide detailed expectations providing how the testimony will go. Practice. Yeah, these are great answers. You guys have some great answers in here. So let's kind of look and go into some of those in a little bit more detail. I'll let Susan take over. So if you're working with the SANE, you always need to meet in advance and that does not mean five minutes before the trial starts. It's very important to sit down with them and it may be important to sit down with them before you actually even prepare with the victim because they can explain what they've seen and what they saw in advance to give you some help. The SANE should review the chart prior to meeting with you. So they should sit down and be very familiar with their chart. They should inform you of any errors ahead of time and I think it's very difficult to do a three to four hour exam without having some errors in your charting. Those errors can be mislabeling of an injury as far as the location on the body diagram. It can be a mislabeling of an injury as far as the location on the body diagram. Those errors can be mislabeling of an injury as far as the location on the body diagram. It can be a word that's misspelled. It can be a sentence that wasn't completed and I think it's important for the SANE to go through their their record and highlight anything that they feel would be an error. Now many sexual assault nurse examiner programs do peer review and if they're doing peer review within a couple of weeks of when the exam is done they may have already noticed an error and written a late entry to explain what the error was and make a correction but for some programs the first time they look at their chart may be when they're getting ready to go to trial and at that point they should not change the record but they need to let you know what the error is so that you can handle it in trial and it not be brought up by first by the defense attorney. You should confirm the attorney's interpretation of the SANE's findings because an attorney may look at the injury diagram and say well there are three sites of genital injury here this is significant and the SANE may say no these are very small injuries they could have occurred as a result of consensual contact and you need to clarify whether the SANE is being used as a fact or expert witness and in many programs if a nurse is relatively new they will be used initially as a fact expert as a fact witness meaning they're going to testify how the exam was performed what samples were collected what injuries were documentation documented and then what you would have is a expert witness come in and interpret those findings for the court. SANE nurse a little more comfortable if she starts out as a fact witness versus starting her out as an expert witness but it's really important to sit down ahead of time so that they know what's expected of them. Susan I wanted to add one and someone had put something in the in the chat about if the patient was seen in the ED to get the entire ED chart so we do know that sometimes sometimes the attorneys don't always have the entire medical chart they may just have what's inside the kit and sometimes that's okay but sometimes it's not especially in senses in situations where the patient also had other medical injuries that were treated so it is important to be clear with the SANE what you are looking at and what you have so that you will have you'll have time to request additional information or additional charting if necessary so that was a good a good point to put up to put in the chat thank you. It's important to know who has access to what I have frequently asked the attorney what the crime lab found in the DNA evidence because that's an important part of the big picture so yes sharing everything with the SANE is important the other thing is the SANE may not have access to the emergency room record depending on their relationship with the hospital and it's important to get that directly from the hospital the other thing is to know that once you get information whether you get it from law enforcement or a hospital or from a patient it loses its HIPAA protections and you can share it with the SANE without worrying about breaching confidentiality in most circumstances I guess it depends on how you're representing your client it may depend on the circumstance and the relationship you have with your client but certainly as a prosecutor if you're prosecuting a case there's nothing wrong with sharing the information you have with the SANE. Susan you bring up a really good point about the SANEs that may not actually be a part of that health care system. SANE programs are set up so differently across the various states right now that oftentimes they actually are not within that ER setting they may have done the exam there but they may not have access to the records of that facility so it would be important to know if you need to subpoena a nurse or another provider from that ER from that health care facility that provided care to that patient that had nothing to do with that the SANE would not be able to speak to so that was a good point Susan. There's a question in the chat about be sure to request photos on subpoena and I would like to talk about photos different programs have different requirements for how they share photographs. I know our program is very comfortable getting consent from the patient up front to share non-genital photographs and law enforcement in our programs gets that immediately and then they have that to share to the prosecutor. In the situation of genital photographs these are very sensitive photographs and we also know that the time from when an exam is done until the time that photographs may be needed for a trial can be a couple of years and as a result of the trauma brain that survivors experience we have decided as a program that we want to go back and re-consent that patient to make sure that they're aware that their genital photographs are being shared with law with another agency typically with the prosecutor's office but we also try to limit that sharing to medical experts because if you've ever seen the photographs that are taken of genital injury they really are not something that are easily interpreted by someone who doesn't have medical experience so we're very we have very strong standards in our state about trying to protect those pictures from any kind of disclosure except to another medical expert and your role as an attorney could be to make a protective order to make sure or to go to the judge and request a protective order to make sure that those photographs are not shared with the suspect or anyone else and that they are returned back to the sexual assault nurse examiner if they cannot be shared in a one-on-one conference with attorneys and the experts so just make sure you think about before you subpoena something make sure you know what you're going to do with those photographs and how you're going to protect them especially the genital photographs great point susan so again always meet in advance with the same you want to let them know you want to let them know what points you want made through their testimony so if you want to make the point that this is a long arduous exam and she's not just she's not reporting the rape just to get back at a boyfriend then let them know that they're going to have to explain that exam there may be things that you don't want the nurse to talk about and that's fine to let them know in advance that doesn't mean if they get asked on cross examination that they're not going to answer those questions they are really independent objective providers of the truth so you may tell them that you're going to avoid that area of testimony but if they get asked by a defense attorney they will have to answer it's also good to try and anticipate how they may be used by opposing counsel and give them a heads up of the things that they might be questioned about so that they're not caught off on caught off guard i mean if you have some idea in advance and you may just from opening statements from opposing counsel of how their testimony might be used that would be a time to maybe meet again with the same and say listen this is the argument that's going to be made by opposing counsel they may need your help with making that argument and then you want to value their time many of us have had the experience of being subpoenaed for three days when we know we're only going to testify for an hour it's really important to work with the same to give them a window for when they will testify and to talk to them about well yeah you're a clinic 15 minutes away i will give you a 30 minute warning or i'll give you an hour warning when i anticipate that i need you to be there and please please please if you find out a trial has settled and is not going to trial don't be the person who gets the phone call from the nurse who's sitting outside the courtroom when there's nobody inside of the courtroom wondering where everybody is and i know many of our nurses have had that experience they show up for a trial and it was um either continued or settled and they were never notified so please um treat your same nurse with tender loving care because uh that's one of the ways to develop a really good working relationship with your sayings yeah that's a super valid point um it is very very frustrating and it takes a lot for the nurses to try to go along and do exactly what they're being asked but the timing i understand is hard for you as a prosecutor or a defense attorney but it's also really hard for for the medical providers too when they're trying to get coverage and all that so yeah just having that open communication and valuing that time is so important so to give you some specific ideas on how to prepare your case um these are some of the questions you should ask yourself and get the answers from the same if you can't get it from the medical forensic record was the patient taking any medications that in might impact examination findings so the example i gave earlier of a post-menopausal woman having a higher chance of injury because of lack of estrogen well if you have a post-menopausal woman who uses estrogen cream to maintain the elasticity and lubrication of her vagina then that may change what you would expect to find as far as injuries and what you actually find does the patient have chronic health problems or previous surgeries that may impact findings so again um someone who's an alcoholic may bruise easier so that information is not just there for our ability to treat the patient but that information may also help us um interpret the findings of the medical forensic exam and the other question you want to be able to ask them is could the time between the assault and the examination impact findings and this is going to occur in several situations so in drug facilitated sexual assault if the time when blood and urine are collected after that assault is several days they may not find anything and that doesn't mean that drugs or alcohol were not used to facilitate the assault but that timing is going to impact the results again we know that injuries in a healthy female heal very quickly so a patient may report that they had bleeding after an assault but if they're being examined two three or four days later there may not be any identifiable injury so asking about that time lapse and how that impacts what they found on the exam can be very important time also um may explain how some of the injuries look as far as healing i think that that points out another good reason why it's important to review the records before you speak with the same because if you see it documented that the nurse has reported that um the patient stated there was um bleeding at the time or but but by the time they came to the exam there there was no blood seen on the examination the same can kind of speak to why that could be so andrea's saying that she has been told to avoid questions and then it was brought up so the question is was it brought up by the um person who told you not to answer that question or by the defense attorney and you have an obligation to be an objective um witness and you have if you are asked a question you are obligated to answer that and if an attorney tells you to avoid certain areas i would say why because they may not have a thorough understanding of the subject and you may be able to explain to them this is why it's important to share this information other other things in the chat that we need to talk about now looking at the chat there's a lot of questions in the chat i think maybe we can try and finish up these last few slides we can maybe address some of these questions because there's a lot of questions okay all right so if you are using a sexual assault nurse examiner as an expert witness there are a couple things you should do and not do one is do not stipulate to qualifications meaning go ahead so if if opposing counsel says we accept nurse jones as an expert i think you want to get nurse jones's credentials education training and knowledge out there to the jury so do not stipulate to their qualifications go ahead and do lay all the foundation you would normally lay to demonstrate that this person is an expert and as we said at the very beginning not all saints have extensive forensic experience but they typically have nursing experience so just to give you an example if you've been an emergency room nurse for two years you can typically say i have taken care of 500 patients with serious injuries and so they now become an expert on injuries i have taken care of 300 patients after they experienced an acute trauma they can talk about how patients react to trauma if they're labor and delivery nurses they have looked at the genitalia of hundreds of women and they know what normal is and what normal isn't and what that part of the body looks like so don't be afraid to qualify someone who's a fairly new forensic nurse as an expert if they have expertise in the area that you need demonstrated to the jury so being prepared for when there's an opposing counsel when the opposing counsel has a medical expert um that can very much happen it actually happens quite often um and that's fine it's totally fine so the opposing counsel may use the same or another provider as an expert witness as well um keep in mind what you are doing while you're up there so your testimony whether you're fact or expert is doing exactly that being objective if you're testifying as a fact witness you're testifying to your um your examination your practice um and you should be able to answer that regardless if that that other expert is in the room or in the room or if you know that they are going to be um presenting something uh presenting something that may go against what you are trying to present right you just have to keep in mind that you you are there as a medical professional that you know your job that you do your job every day and you have the ability to um to explain what you're doing and why you did it right you saw the patient typically if you're the fact witness you saw the patient and you did the exam so you're really speaking to what you saw um what you heard from the patient what you did in your practice and let that expert speak about what what they're there to testify don't be afraid of that okay um but on the other side of it is understand exactly what their qualifications are right make sure that as the attorney that you are familiar with their resume their cv and then what is their experience what are they actually providing you expert testimony on so that you can prepare your witness um as to what what they need to focus on in their examination as they explain their examination with the what in their testimony and i can just tell you that both sides keep a list of their experts and typically have examples of other experts testimony so that if you know that jane smith is coming as a opposing council expert to testify in your case reach out to people in your community and find out what their experience has been with that expert in the past um as the statewide sane coordinator for utah i frequently have prosecutors reach out to me to ask about expert witnesses not just in for sexual assault nurse examiners but for other areas of expertise around the sexual assault exam we also talk we also have people in our state who are qualified to talk about the psychological response of sexual assault victims i just made a referral for someone who can talk about uh suspect behaviors or offender behaviors so don't be afraid to use your sexual assault nurse examiner resources if you have a need for an expert witness or you need to know about an expert witness right exactly because a lot of times that if you let them know that you have this expert over here and you need someone they may very well be able to connect you with someone um that you can reach out to and see if they can be an expert as well and i also don't have any problems when a defense attorney calls me and says i need an expert witness i'm willing to share the local um experts for this for the defense attorney also because the we want the truth to come out during a trial we want the best outcome possible for the criminal justice system and that means that we support good testimony on both sides of these cases and also be familiar with your resources so of course the victim's rights law center is an awesome resource but also um oftentimes they have um they have the ability to assist you with this what with finding expert witnesses so know your resources and use them and just remember that the opposing expert most often did not examine the patient right so most often they are testifying to um to the research they're testifying to um the experience and the science so just keep that in mind that why exactly is that expert being called and then what is their testimony going to look like what are they testifying about angelita this is jesse i just wanted to mention for folks who may not know that equitas is also a ta provider funded by the office and violence against women and they're funded to support the work of prosecutors who are prosecuting crimes of gender-based violence such as sexual assault domestic violence etc and all of their attorneys are former prosecutors so they're also just a terrific resource for folks who are involved in the criminal justice system um we work with them closely so i was really glad to see that you mentioned them as well and it's i'm not sure of their contact email but i will find it and put it into the chat box as well thanks jess that would be great um so we just want everyone everyone here today to recognize education is good for everyone right so for all the attorneys on the line or on this webinar be available for your sayings assist in their same trainings assist in their continued education sessions um do something individual with their programs to help them um interact a little bit better and build up on their testimony skills and then for the medical providers the sayings and the um forensic nurses that are on the here a request to be a part request to be in trainings with the attorneys try to reach out to them build that connections if you are on a start and you're um the attorneys are represented in your start have communication on how you guys can educate each other to better provide the best testimony possible um for the cases that you handle together it's super helpful and it does it just continues to to build um to build that better relationship to be able to to serve the clients better so we've pretty much reached the end of the webinar um there's a few resource slides coming up this right here i talked i talked earlier about how um ifn has a project called safe ta that would provide technical assistance around anyone or to anyone that um that works with patients of sexual violence so this is some contact information you can reach out with questions or to connect um via email you just go to contact at safetya.org so c-o-n-t-a-c-t at safetya.org or we also have a resource a professional resource on 1-877-819-7278 or also 1-877-819-SART and then this is contact information specific to myself and susan if anyone wanted to reach out to either one of us with additional questions so it looks like we have a little bit of time susan i don't know if we're going to try to tackle some of these questions in the chat here well i like the comment from sam that um any suggestions on when a defense attorney ask about being a male sane and i would say if that's all the defense attorney can ask you about obviously um that's the you're in good shape because it means that's the only thing they can think of to attack you on i would just say that i'm not aware of any um nursing job that is limited to either males or females that like all nursing jobs sexual assault nurse examiners can be males or females that there is no area of nursing practice that i'm aware of that has a um gender um exclusion and i think that that that male saying would be able to testify to their experience of providing care to their patients not just their sexual assault patients to all their patients um so that in itself speaks for itself um let's see um i think that i think the term you were thinking of was bfoq from first year law school class modified occupational qualification it's not yeah no it is i forgot to i and i think this is jesse i neglected to mention in my introduction by the way that um in addition to all the various uh nursing and qualification letters following susan's name um she's also held a jd from law school it was in a moment of weakness um one person comments it should be made very clear the same doesn't work for law enforcement they work for the patient and i think that's an excellent point to make and that you should be able to justify everything you do as a something that you would do in practice of taking care of a patient yep i was going to pull that same comment thanks susan um i have to get past our chat question because there were questions before our chat question so someone is asking about um can you share your process for consenting for photos so we consent at the time of the exam to release the non-genital photographs and and it actually does include genital photographs but we explained to them at that time that they are not released immediately and that if it's been a period of time we want the patient to be aware that that's being shared because they don't remember one of my worst testimony experiences was a trial where um they wanted to use the testimony of the victim to create a foundation to enter the photographs into evidence and she got up on the stand and they said did you have pictures taken such and such a night and she said yes and did you have pictures taken at the clinic and she said no because she didn't remember she'd had pictures taken at the clinic she'd had pictures taken at the police department and the clinic and she basically said no and therefore those pictures could not be entered into evidence because she just the trauma of what had happened two years earlier she did not remember so we feel that's really important to let patients know if those photographs are going to be reused and I think it's also really important for them to be clear that if they're signing that release ahead of time that once those photographs are not released out of the healthcare system that again HIPAA no longer applies so they need to understand that whoever they're releasing that to can share that with whoever they choose to share it with um because it's no longer a HIPAA thing so that that's really important for them to understand and maybe they would be able to reach out to either if it's going to law enforcement who is law enforcement going to send it to from there if it's going to the prosecutor's office clarifying with the prosecutor what they intend to do with those photos especially the genitalia photos and most judges and juries and attorneys really don't want to look at those photographs um so it's usually not a hard fight to fight it really they really typically are reserved for the use of medical experts to review what was seen in the case there's also a question here that says um what can the defense not ask a safe i.e. have they been a rape victim and i don't know that that's a sane specific question certainly i hope um that if it were in the context of a criminal case the prosecutor would make an objection on the grounds of relevance but i don't know angelita or susan if you've ever been in a courtroom or heard from a sane who has asked that question and how it unfolded so what we have had that happen if the prosecutor does not object i would instruct um the same to turn to the judge and ask do i need to answer that question so the prosecutors i shouldn't say this asleep at the wheel um i i and because again now if the judge says yes you have to answer that question then you have to answer it but um i think if the prosecutor doesn't catch it it's all right for the nurse to turn to the judge and say do i need to answer that question about my personal life yeah i've been asked that before um but i did have a great prosecutor who objected right away and they took a bit of a recess to talk about it so um there is a question about research and um does research expire it looks like hayley put out there that research should be between five to seven years you do want to try to use the most current research but you also want to be you also want to be aware that sometimes the research is limited so you may have to use older research but being able to explain that so there's a question about how much personal information can they ask it depends on why they're asking it so if you have posted all over facebook that you think the suspect in the case is a horrible person and should go away for 20 years they can ask you about that even though that's personal information because it goes to show your bias so if they're trying to prove that you're a biased witness they may be able to ask personal information um if they can lay that foundation So in reconsidering for photos, how is the trauma of survivor has experienced considered. I mean, it's like any other thing we're going to call them and explain to them why it's needed. And what the implicates informed consent, like you do with any situation. It's why these photographs are being needed, how they'll be used. And what are the consequences if they say no they can't release the photographs, so that it's it's informed consent, which is something we do as nurses every day. Okay. Just trying to go back to the top and see if there's anything that we missed. So there's the question about rough sex and injuries. What about the question on the difference between consensual rough sex and entries post non consensual sets. I tend to want to ask somebody to define what rough sex is because I don't know that there is a medical definition of rough sex, I don't know there's a research definition of rough sex. So I want them to define to me what rough sex is before I would answer that question. And you're always at, you're always able to say, I'm sorry I can't answer that question, as it's been asked, or can you clarify, or I'm not sure what you're asking there. There were a couple questions earlier in the chat about certification specific if you guys could just reach out to me via email, I will gladly address those questions for you specifically my email again I will put it in the chat. I think someone may have put it there but I'll put it in the chat just just for all of you to be able to email those specific questions. Is it okay for the defense attorney to ask why you became a SANE nurse? I don't think there's a problem with asking that. I would take a minute and stop and think about that answer. I mean, the answers are a lot. I mean, there are a lot of different answers for why people did that. I work with a lot of rural SANE programs in Utah, and I think the major reason why people do it is because they want to provide this service to their community. They want victims to be taken care of the way they feel they deserve to be taken care of. My reason for doing it was because I was told by an emergency room nurse that it would be illegal for a nurse midwife to perform a sexual assault exam because it would be outside of her scope of practice, and I was like, I don't think so. So somebody told me no, that's the reason I decided to do it. I was just going to say. I see a question here, whether you can answer a defense question with a question, whether you may versus whether it's a good idea, I think are two different things. I think if there's an issue with the question that a defense attorney asked, my suggestion would be to sort of have some way of looking at the prosecutor, sort of waiting for them to intervene if it's an inappropriate question or like Susan suggested, if it's something that's very personal that you aren't wanting to answer to ask the judge, but everyone has their own style and approach, I think, to being any kind of a witness. Sorry, you can always ask them to repeat the question, to clarify the question. That's not. Yeah, that's what I was going to say. I think that Virginia, that question would have to be even a deeper question. Are you asking them a specific question? Are you not understanding what they ask you? So I was just going to say that same thing, like you can always say, can you please clarify your question? I would say, I read it as someone wanting to be just asked back because the defense is being annoying or obnoxious. Yeah, no, don't do that. I mean, your job is not to make the defense attorney look bad or oppose or anybody. You may be the defense expert. Your job is not to make the prosecuting attorney look bad. Your job is to testify to what you saw, know, your expertise, and your testimony should not change based on whether or not you're testifying for the defense or for the prosecution. I think that's something that helped me over the years was to really think about what the defense attorney is doing. So they're trying their best to do their job. They don't have to be nice about it, but we get a little defensive about it because they're trying to find something to to work with. And so we just kind of have to try our best not to be frustrated by their questions, especially if they're repeating. So at one time I had a defense lawyer ask me the same exact questions five times in a row. And my answer didn't change because that was the answer that I had. But, you know, it was hard not to become frustrated because I felt like they were trying to trip me up. But the reality is they're really just trying to do their job. So I do want to answer the question about handing over the same report. So there is a little bit of confusion out there. If you are functioning as a nurse, I'm not sure how you can justify that your report is not a medical record. And under HIPAA, that medical record is accessible to the patient. I mean, I and I'm not giving anybody legal advice, but I think it's very important to recognize that our primary function is to provide patient care. If our primary function is to provide patient care, then the record of that care is a medical record. And under HIPAA, if you have created a medical record, the patient should have access to it. That is part of the patient's rights. And I think this arbitrary that you that there are people who are basically in an arbitrary way saying it's a forensic record and therefore the patient's not entitled to that. Well, if it's a forensic record and the patient's not entitled to that, then you must not be providing nursing care. And I don't know how you separate out the forensic from the nursing. I think that, again, becomes very arbitrary. So I think you need to be very careful with that approach. In reality, we know, at least in my state, that less than 90% of our patients will ever see a courtroom or have a criminal justice outcome. And therefore, when I walk into that room, I am in nurse mode. I am there to take care of that patient the best way I can. If they want a copy of their medical record, I have absolutely no problems sharing that with them. I don't want to just email it to them or mail it to them. I would like for them to come in and sit down and let me go over it with them. Again, because of that trauma brain, I may have written something in there that they will not understand. So I think it's important to sit down with the patient and go over that medical record with them first. But I have absolutely no problems releasing it to them. Monica, I would be really interested in connecting with you to learn a little bit more about the situation. Because maybe there's more to that that we aren't really aware of or familiar with. But yeah, that should be part of a medical record. And they should be able to reach out to the medical facility to actually get, or whoever presided the exam, if it's a community-based saying, somewhere there has to be an actual medical record there we would hope that they could have access to. So please feel free to reach out to IFN so we can talk about that a little bit more and help to rectify, or give suggestions to help rectify that situation. And this is Jessie. I'll echo that offer, because this is an issue that I know IFN and the VRLC have been in conversation on for, gosh, at least half a dozen years or more. And it's something we've done some research into regarding specifically patients' rights to access their medical records. There's a comment there about when the prosecutor, when the nurse works for the prosecutor. I'm hoping she doesn't work for the prosecutor. I'm assuming that we're talking about states where there's a state I'm aware of where the SANEs are employed by the prosecutor's office. But I hope they are there to take care of the patient and that they're still there in their role as a nurse. And I'm not aware of if they've ever been challenged by having their employer be the prosecutor's office. Hopefully they have very strong protocols that make it clear that their role is a nursing role and that they meet all the nursing standards of licensure and malpractice and all the things that they have to do to be a nurse and to provide that care under their state nurse practice act. Yeah. There's one more comment in here that is specifically talking about child sexual abuse and the SANE record. I just wanted to throw out before we have to close down that there has to be some policies in place within an organization as to what the release of the record will look like for the pediatric patient in regards to the parents and to guardians when the investigation is in process. And it may look differently from state to state and from organization to organization as well. So just a little. And there is an exception in HIPAA to release records when a child might be in danger. Yeah. So again, that's why hopefully if you're making protocols and policies and doing things that you're not basing it on what Angelita and I say today that you are working with your local counsel and legal advisors to make sure that whatever you're doing not only follows the national laws like HIPAA and EMTALA but also follows your state privacy laws because HIPAA provides the floor for privacy. It's not the ceiling. And many states have further defined privacy for patients and medical records beyond what HIPAA has said. So you really need to consult with legal counsel in your state who are familiar with both state and federal laws. And your legal and risk management in your department of your facility if you have one. That's really important. Well, I can see that we are exactly on the half hour so perfect timing, Susan and Angelita. Thank you so much to everyone who participated today, who attended, who posed questions and made comments into the chat box. We're just so happy to have you engage and to be answering the questions that you've presented and that were just really terrific. And especially, first of all, a thank you to Angelita and also to Susan for this terrific content. And all of you for the work that you do every day, we're so grateful to you. It really does take a village. It takes the advocates and the survivor-centered lawyers and the SANEs who are providing the excellent medical forensic exams and other medical care. And so all of us going forward together to provide the best services and support and care that we can for survivors. So thank you to all of you for participating today. And thank you again to THTA for hosting us. We will be sending out the PowerPoint and we'll also be sending out those VRLC resource request forms. And for the nurses that are on, you will get an evaluation link that will come out that you can take the evaluation for your nursing continued education credits. And thank you in advance to everyone for completing the evaluation. We always look at your comments. We look at your feedback and we greatly value it. Thank you again for participating and for all your great work.

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sexual assault nurse examiners

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