Attachment 2e - Medical Forensic Documentation Forms.pdf

Step 2 Illinois State Police Division of Forensic Services

Patient Label

Medical Forensic Documentation Forms page 1

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 1

Patient Information:

Legal Name: Current Name:

Address:

City: State: Zip: County:

Contact Number:

DOB: Age:

Sex Assigned at Birth: Race:

Avoid multiple interviews. Take time to establish rapport. Avoid leading or yes/no questions. Use direct quotes whenever possible. Avoid surprise or negative emotions, while still showing concern and support.

Patient History of Assault:

Date of Assault:

Time of Assault:

Location/ Physical Surroundings of Assault:

Name and/or Description of Assailant(s): (If assailant is under the age of 18, document age if known)

1.

Relationship to Patient (if known):

2.

Relationship to Patient (if known):

3.

Relationship to Patient (if known):

Examination Information:

Examiner:

Exam Date:

Exam Begin Time:

Medical Facility:

Medical Facility Contact Number:

Name of Guardian:

Person Providing History:

Relationship to Patient:

Persons Present During Exam:

Patient Label

Medical Forensic Documentation Forms page 2

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 2

Information provided by: _____________________________________________________________________

Description of what happened: Please provide legible account and attach additional pages if needed. Use direct quotes whenever possible. If patient is less than 13 years of age, avoid leading or yes/no questions.

Patient Label

Medical Forensic Documentation Forms page 3

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 3

Acts Described by Patient/Historian o Information not obtained at this time due to patient being pre-pubescent, unconscious, intubated, or other (please explain) _________________________________________________ (Go to page 4):

Penetration of Female Sex Organ (Vulva) by:

Penis: Yes No Touched Unknown

Finger: Yes No Touched Unknown

Object: Yes No Touched Unknown What:

Mouth: Yes No Touched Unknown

Penetration of Anus by:

Penis: Yes No Touched Unknown

Finger: Yes No Touched Unknown

Object: Yes No Touched Unknown What:

Mouth: Yes No Touched Unknown

Did Patient Have Oral Contact with (If yes, Miscellaneous Swab Collection Envelope may be appropriate)

Female Sex Organ (Vulva)

Penis: Yes No Unknown N/A

Anus: Yes No Unknown

Mouth: Yes No Unknown

Other (including biting):

Did Assailant Have (If yes, Miscellaneous Swab Collection Envelope may be appropriate)

Penis: Yes No Unknown N/A

Mouth: Yes No Unknown

Other (including biting):

Was any part of the body kissed, licked, sucked or bitten? (If yes, see Miscellaneous Swab Collection Envelope) Yes No Unknown

Describe: _________________________________________________________________________

Did Patient Scratch Assailant: (If yes, see Fingernail Specimen Envelope) Unknown

Did Ejaculation Occur Outside: (If yes, see Miscellaneous Swab Collection Envelope)

Yes No Unknown Where: ________________________

Did Ejaculation Occur Inside: Yes No Unknown

Condom Used by Assailant: Yes No Unknown

Where Discarded: Unknown

Patient Label

Medical Forensic Documentation Forms page 4

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 4

Methods Used by Assailant(s):

o Information not obtained at this time due to patient being pre-pubescent, unconscious, intubated, or other (please explain) ___________________________________ (Go to page Post-Assault Hygiene/Activity):

Weapon(s): Describe________________________________

Punched/Slapped/Kicked: Describe________________________________

Grabbed/Held Down: Describe________________________________

Physical Restraints: Describe________________________________

Burned: Describe________________________________

Verbal Threats: Describe_________________________________

Use of Ligature: Describe_________________________________

Strangulation: ________ (If yes, complete a strangulation assessment)

Other_____________________________________________________________________________________

Post-Assault Hygiene/Activity:

Urinated: Yes No Vomited: Yes No

Defecated: Yes No Ate/Drank: Yes No

Genital Wipe/Wash: Yes No Brushed Teeth: Yes No

Bathed: Yes No Chewed Gum: Yes No

Showered: Yes No Smoked: Yes No

Clothing change Yes No Douched: Yes No N/A

Removed/Inserted a Tampon, Diaphragm, Sponge, Maxi pad (circle): Yes No N/A

If the patient answered yes to any of the above questions, consider collecting toxicology samples. A urine specimen should be collected as evidence if DFSA is suspected. DO NOT INCLUDE URINE SPECIMEN IN THE KIT. The urine should be sealed, labeled and packaged separately and turned over to law enforcement per patient consent.

This form is available at www.isp.illinois,gov under the Forensics tab.

Urine Sample Obtained for Crime Lab: Offered and performed Offered and declined N/A

Was underwear Was clothing collected:

Describe condition of underwear and/or clothing: _____________________________________________________

Drug Facilitated Sexual Assault (DFSA):

Loss of Memory: Yes No

Loss of Consciousness: Yes No

Nausea/Vomiting: Yes No Drug/Alcohol Use by Patient: Yes No Describe: __________________________________

Underwear and Clothing Collection:

Patient Label

Medical Forensic Documentation Forms page 5

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 5

Pertinent Medical History for Forensic Lab:

Last Menstrual Period: Date:_ N/A Sexual Contact within 3 Days (other than sexual assault): N/A

Female Sex Organ (Vulva) Contact: N/A Penile Contact: N/A Anal Contact: N/A Oral Contact: N/A

Condom Used: N/A

General Exam:

Record all trauma on the diagrams below which may be used in a criminal proceeding. Trauma includes: burns, lacerations, abrasions, redness, scratches, bruises, bites, patterned injury, fractures and stains/ foreign materials on body, swelling, and tenderness. Be sure to note even the most minor signs of trauma. Document size, shape and color description for all findings. Add another page if more space is needed. Indicate if photos were taken, ALS used, patient report of how trauma occurred, etc.

Right Left Right Left

Patient Label

Medical Forensic Documentation Forms page 6

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 6

General Exam cont.:

Record all trauma on the diagrams below which may be used in a criminal proceeding. Trauma includes: burns, lacerations, abrasions, redness, scratches, bruises, bites, patterned injury, fractures and stains/foreign materials on body, swelling, and tenderness. Be sure to note even the most minor signs of trauma. Document size, shape and color description for all findings. Add another page if more space is needed. Indicate if photos were taken, ALS used, patient report of how trauma occurred, etc.

Alternative light source used ____

Right Left Left Right

Patient Label

Medical Forensic Documentation Forms page 7

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 7

Genital Exam:

Record all trauma on the diagrams below which may be used in a criminal proceeding. Trauma includes: burns, lacerations, abrasions, redness, scratches, bruises, bites, patterned injury, stains and foreign materials, swelling, and tenderness. Be sure to note even the most minor signs of trauma. Document size, shape and color description for all findings. Use hours of the clock to describe location. Add another page if more space is needed. Indicate if photos were taken, patient reports how trauma occurred, etc.

Lateral-Down Separation: Yes No N/A Describe: _______________________________________ Outward Traction: Yes No N/A Describe: _______________________________________ Toluidine Blue Dye: Yes No N/A Describe: _______________________________________ Foley Cath/Fox Swab: Yes No N/A Describe: _______________________________________ Ano-genital Photos taken Yes No

Sexual Maturation Stage/Tanner Stage: Exam Positions: Lithotomy - Leg Breast 1 2 3 4 5 N/A Supine Knee Chest Pubic Hair 1 2 3 4 5 ________________

Circumcised: Yes No Foreskin retracted: Yes No Testes descended: Yes No

Internal Exam: Anal Exam:

DO NOT PLACE A SPECULUM in a prepubescent female child. A minimal amount of water soluble, non-spermicidal lubricant or sterile water may be used for lubrication when speculum insertion is appropriate. Note injuries on diagram.

Yes No

Hymen Description:______________________________

Declined exam N/A

Declined exam N/A

Declined exam N/A Prepubescent

Declined exam

Patient Label

Medical Forensic Documentation Forms page 8

ISP 6-002 (1/23) White (Original) to Hospital Medical Record; Yellow in Kit 8

Photographs:

Photographic documentation of injury and/or other visible evidence can be utilized to supplement the medical forensic history and written documentation. Consider the extent of forensic photography necessary. Be considerate of patient comfort and privacy. Take photographs according to hospital policy. Photographs taken by examiners should be

Photographs may If under the age of 13, the parent or guardian may provide consent. If the parent or guardian is not immediately available or refuses to consent, photographs may be taken and stored for release at a later time with consent of the investigating law enforcement officer or the Department of Children and Family Services.

Any Additional Comments/Findings: Should not reflect any conclusions regarding whether an assault occurred.

lab abnormalities, additional interventions, safety plan (DCFS, shelter, etc.).

Documentation:

If the patient is less than 18 years of age, was DCFS notified, if appropriate?

If the patient is 60 years of age or older, was the Department of Aging notified, if appropriate?

If the patient is between the ages of 18-59, has a disability, and is unable to self-report, was the Department of Aging notified?

Was Consent: Collect and Test or Collect and Hold form completed?

Were police notified? If no, indicate why: __________________________________________________

Yes N/A

Signatures:

(Examining Health Professional Signature)

(Assisting Health Professional Signature)

(please print) (please print)

Final Instructions:

1. All information requested on sample envelopes and bag labels are completed.

2. Separate forms and follow distribution requirements on the bottom of each form.

3. If underwear and/or clothing bags and urine are collected: seal, label, and package separately from the kit.

Complete Toxicology Consent form. DO NOT PACKAGE URINE, UNDERWEAR OR CLOTHING INSIDE THE KIT.

4. Return all evidence envelopes to the kit box.

5. Initial red evidence tape and secure to kit box.

6. Fill out information, as appropriate, on top of box.

7. Hand the sealed kit, sealed bags, and sealed urine sample to appropriate law enforcement agency.

NOTE: If law enforcement is not present: place sealed kit, sealed bags, and sealed urine sample at room temperature in a secure area, maintaining chain of custody until law enforcement can collect the evidence.