Completion of Medical Report

(See sample at pages 22 through 25).

Specific Instructions

  • In Section 2 of the Medical Report record patient’s account of the sexual assault, including information such as gender of assailant, and number of assailants, etc.
  • If information requested in Section 2 of the Medical Report is recorded elsewhere, such as on a physician’s consult form, include a copy of that form with the yellow copy of page 1 in the envelope on the Kit box bottom.
  • In Section 2 of the Medical Report ask specifically about contact, penetration and ejaculation.
  • In Section 3 of the Medical Report document other sexual activity of the patient only if it occurred within 120 hours prior to the assault.
  • In Section 3 of the Medical Report record medical history such as present illnesses, medications, drug allergies, gynecological history, etc.
  • In Section 4 of the Medical Report provide a detailed description of the patient’s outward appearance.
  • In Section 4 of the Medical Report provide details regarding any marks, bruises, etc. on the patient’s body. Be sure to indicate the location on anatomical drawings.
  • In Section 5 of the Medical Report provide details regarding any injuries and/or signs of trauma in the area of the patient’s genitalia. Drawings are important even if  photographs are taken. (See page 50 for information regarding photographs).
  • In Section 5 of the Medical Report provide details regarding the patient’s observable behavior during the examination.
  • In Section 8 of the Medical Report record impression/diagnosis (e.g., “sexual assault by History,” or “examination and history consistent with patient’s complaint of sexual assault”).
  • Section 9 should be completed to indicate whether photographs were taken. (See page 50 for information regarding photographs).
  • Section 9 should be completed to indicate whether a forensic odontologist was consulted. If “Yes” is checked, record details, including the name of the odontologist, in section  9.
  • Section 9 of the Medical Report should be completed by the nurse/physician and the officer who completed the transfer, respectively, when collected evidence is transferred to police custody.

Necessary Signatures

  • The nurse or physician completing each designated group of sections should sign or write her/his name on the appropriate lines as required by the Medical Report form.
  • The signature section following Section 9 of the Medical Report should be completed by all medical personnel who participated in the completion of the Medical Report.
  • If an interpreter was  involved in the translation of the questions and/or responses contained in the Medical Report, print that person’s name, address and phone number in the spaces provided following Section 10.
  • When evidence is transferred to police custody, the nurse/physician and the officer who completed the transfer should complete Section 9 of the Medical Report. (See page 62-64).

 Distribution of The Medical Report

  •  When all pages of the Medical Report are completed, place the white copies (and any supplemental pages) in the patient’s medical record, and place the yellow copy of the first page (and copies of any supplemental pages) in the envelope on the bottom of the Kit box.
  • If a Kit is not completed, place all pages in the patient’s medical record.