Importance of the history and exam findings

Recognize the importance of gathering information for the medical forensic history, examining patients, and documenting exam findings, separate from collecting evidence.  Examiners should obtain the medical forensic history as appropriate, examine patients, and document findings when patients are willing, whether or not evidence is gathered for the sexual assault evidence collection kit. The history and documentation of exam findings can help in determining if and where there may be evidence to collect and in addressing patients’ medical needs. In addition, they can be invaluable in and of themselves to an investigation and prosecution if a report is made. It is also important to document patients’ demeanor during the exam process (e.g., crying, shaking, or showing signs of upset) and their statements made related to the assault because if the case is reported, this information could be admitted as evidence at trial.


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