KMA Model Health Care Protocol on Abuse, Neglect & Exploitation Child, Spouse/Partner, Adult & Elder

IV. ASSESSMENT, EXAMINATION, & DOCUMENTATION

A. General Information

To assist physicians to thoroughly assess and document cases of known or suspected child or adult maltreatment, model forms have been devised as follows: 1) Interviewing and History Taking for an Adult; 2) Interviewing and History Taking for a Child; and 3) Interviewing the Family/Caretaker.

These assessment forms should be readily available to all medical and Community Based Services personnel. The models are included with this protocol and may be photocopied for distribution and use. See VI. Model Policy & Assessment Forms. It is recommended these copies be on color-coded sheets or marked for easy recognition.

Assessment & Documentation Forms Pink = Children Red = Spouse/Partner Orange = Vulnerable Adult

1. Purpose of the Examination

A thorough medical examination is an extremely important part of the investigation of allegations of maltreatment. The purpose of the examination is to:

• document any injuries and/or the condition of the patient;
• diagnose and treat injuries and/or condition of the patient, including any sexually transmitted infections; and,
• reassure the patient and addresses any concerns about her or his physical/psychological well-being. (Many victimized patients fear they are to blame in some way, or are ‘worthless’.)
• collect and preserve evidence.

Be sure to ask about and look in areas where injuries are likely to occur: areas covered by clothing; bilateral surfaces (e.g., arms, neck, legs).

Physicians need to be particularly thorough in their assessment of the elderly so as not to confuse signs of aging, effects of medications, or basic problems of caring for a fragile dependent or bedridden adult (or child) with signs of maltreatment.

2. Interviewing Techniques

Many victims will not readily volunteer information about their maltreatment for a variety of reasons (e.g., shame, fear, ‘love’). However, most will discuss it if asked simple, direct, non-judgmental questions in a private setting. Use professional interpreters when needed, rather than a patient’s friend or family member.

Contrary to early speculation that adult and child victims “don’t tell” or “won’t talk” about the maltreatment occurring to them, research indicates that victims repeatedly turn to a variety of professionals for help, including health care professionals. The physician’s approach to these patients can influence whether or not they receive the treatment they need. It could also affect their awareness of and ability to obtain protection and related assistance.

In as private a setting as is possible, the patient should be encouraged to reveal as many details as possible concerning the maltreatment. If a patient, especially a child, requests a support person (e.g., advocate, parent, caregiver), this person may be allowed to remain with them during the interview. Consent to have a support person present must be given by the victim prior to the introduction of that person in the process. Try to arrange for the person to sit so as not to be able to receive or send cues to the patient.

Helpful Hints: (Tipton, 1989)
Setting:	Establish a private, emotionally neutral, relaxed atmosphere. Be at eye level and maintain eye contact.
Credibility:	Establish your identity and right to interview the patient. Obtain consent as is appropriate. Informed consent should be a continuing process. Give complete attention to the patient; try to be eye level. Protect the privacy needs of these patients avoiding discussion of their cases except where appropriate.
Time:	Where appropriate, assess the patient’s sense of time. Use this knowledge to clarify the chronology of important events.
Terminology:	Clarify meanings of colloquial terms (e.g., anatomy). Use the patient’s terminology when appropriate. Clarify patient’s interpretation of any threatening comments (explicit/implicit) or behaviors by the alleged perpetrator.
Questions:	Try to ask open-ended questions. Explain the importance of detailed and comprehensive medical records. Allow ample time for the patient to respond. Keep in mind the sensitive, and high-risk, nature of the situation.
Nature & Extent:	Try to elicit and document the 1) type of maltreatment; 2) sites, type of injuries/pain sustained; 3) duration and progression of maltreatment over time; 4) identity of the alleged perpetrator; and 5) any direct or indirect threats (e.g., secrets, ‘you’ll be sorry’) to prevent disclosure.

SAMPLE STATEMENTS FOR PATIENTS

• “We often see people with injuries like yours. Sometimes they are the result of a family argument or frustrations related to caring for someone.”
• “How do you feel about what happened?”
• “Because injury affects the health of so many (women, children, elderly) I’ve begun to regularly ask about it. Have you been hurt or in fear of being hurt?”
• “ Would you like to talk about what happened to you?”
• “I realize this is very difficult to talk about.”
• “Are you afraid to talk about it? What do you think will happen if you do?”

The adult or child victim may initially deny or minimize the maltreatment. If the strategies outlined previously are not productive, ask more direct questions about possible maltreatment. Save delicate questions for last. Follow-up interviews may be necessary to obtain a more complete history.

Where a patient has difficulty communicating because of disability, age or condition, allow ample time for the patient to respond. Let the patient share information through their best means of communication (i.e., gestures, bliss board, writing, typing, etc.) When there is a need for an interpreter (including Sign Language), arrangements should be made to promptly arrange for this assistance per standard policy.

Maintain an open and non-judgmental demeanor throughout the interview no matter how disturbing the patient’s story. Personal feelings should not interfere with providing optimal care

3. Legal Significance of the Medical History

Information obtained during a medical interview may be admissible as evidence in court. Questions which are phrased to suggest an answer are inappropriate. Accordingly the interviewer must be careful to use open-ended, non-leading questions. Moreover, the interviewer should attempt to document:

• the time elapsed between the most recent episode of maltreatment and the patient’s statements;
• whether the patient’s statement was made in response to questioning of the practitioner or was spontaneous;
• whether the statement was elicited by open-ended, direct, or leading questions;
• the patient’s emotional state at the time of questioning (also record non-verbal responses to questions);
• the patient’s physical condition at the time of the statement;
• who was present when the statement was made;
• the characteristics of the event (maltreatment) and the exact words used by the patient;
• whether the statement was made at the first opportunity when the patient felt safe to talk;
• whether the patient had any apparent incentive to fabricate or to distort the truth.
  (Katie Bright, MD, University of Kentucky, 1993)

4. Special Needs Patient

The “well-known” patient may in fact be a victim of adult or child abuse, neglect or exploitation. Such patients are generally met with skepticism and may be provided symptomatic treatment. The presenting symptoms may be so general (e.g., sleep disturbances, abdominal pain, enuresis, encopresis, or phobias) that caution must be exercised when the pediatrician considers sexual abuse. …American Academy of Pediatrics, 1999. Review of previous health care records may reveal a trauma history consistent with maltreatment embedded in a myriad of normal exams and seemingly insignificant complaints.

The treating physician is responsible to assure identification, treatment, documentation, reporting, and records are appropriately and consistently addressed for all patients. In cases of adult or child abuse or neglect, reporting to law enforcement or Community Based Services is mandatory under KRS 209.030 and KRS 620.030-050. Bias or prejudice of any kind (race, ethnicity, religion, gender, sexual orientation, etc.) must NOT be tolerated or concealed. This applies even when physicians treat a patient (possible victim of maltreatment) who is a colleague or family member of a colleague (regardless of position); a public official; or a prominent citizen.

Where a disabled patient has difficulty communicating, go slowly and let the patient tell the story through her or his own method of communication (e.g., gestures, bliss board, etc.) Allow the patient to use his or her own words to describe body parts or experiences.

The seriously depressed or psychotic patient may not be able to relate a history of abuse, but a review of medical and emergency room records may document previous injuries resulting from maltreatment. An identified history of abuse, neglect or exploitation should then be integrated into the psychiatric evaluation for use in subsequent referral and treatment plans. Suicide attempts, as a manifestation of abuse, neglect or exploitation, are rarely identified. Many patients are simply discharged without appropriate diagnosis, report or referral for follow-up protection and counseling.

B. Physicial Abuse/Neglect

1. When and Where to Examine

Adult and child victims of maltreatment, especially sexual abuse, should be seen as expeditiously as possible. If the patient is obviously injured, especially if there is bleeding, an emergency exam is indicated, and an Emergency Room would probably be the best location. In many centers, the Sexual Assault Nursing Examiner program (SANE) is utilized for these exams. In Kentucky, a SANE is licensed to examine children 14 years and older. If there is no serious trauma noted, a Children’s Advocacy Center may be consulted for victims 0-18 or adults with developmental disabilities can provide a comprehensive medical examination, mental health screening, forensic interviewing (or equipment and facility) and court advocacy services.

Due to the chronic nature of some cases, many victims may not be identified until weeks or months after the most recent injury or contact (e.g., sexual). This should be taken into account when deciding when and where to schedule a medical evaluation. “The diagnosis of child sexual abuse often can be based on a child’s history. Physical exam alone is infrequently diagnostic in the absence of a history and/or specific laboratory findings. Physical findings are often absent even when the perpetrator admits to penetration of a child’s genitalia. Many types of abuse leave no physical evidence and mucosal injuries often heal rapidly. Occasionally, a child presents with clear evidence of anogenital trauma without an adequate history. Abused children may deny abuse.” …American Academy of Pediatrics, 1999.

The elder victim of maltreatment is generally more difficult to assess because of coinciding chronic debilitating illness(es). Findings may be subtle. Look additionally for subtle signs of neglect or abuse, such as dehydration, malnutrition or wasting; decubiti or contractures; excessive dirt or odor on body or clothing; urine burns; glasses, dentures, hearing aids, or walking devices in poor repair; presence of fleas or lice; or over- or under-medication, esp. sedation.

2. Attending Personnel

Only the examining physician and attending nurse should be with the patient in the examination room. There may be instances when a patient requests (and consents) to the presence of a close friend, family member or trained support person/advocate. If possible, these requests should be honored. All persons present during the examination should be documented in the patient record.

There is no medical or legal reason for a law enforcement representative, male or female, to observe the medical examination. Maintaining the chain of evidence during the examination requires no outside assistance and should strictly be the function of the attending medical personnel.

3. Nursing Responsibilities

In accordance with health care facility policy and Kentucky Board of Nursing guidelines, the following patient examination responsibilities should be delegated to the appropriate nursing personnel (i.e., RN, L.P.N., or other nursing personnel).

• Prepare the room for examination. (See also Sexual Assault Examination below.)
• Measure & record the patient’s height, weight and vital signs in the chart.
• Assist the physician and/or Sexual Assault Nurse Examiner with the physical examination.
• Completely label all laboratory specimens collected in the examination.
• Verify the specimen containers are properly marked before the specimens are taken from the exam room.

Ensure the laboratory specimens are taken expeditiously to the appropriate lab facility.

C. Sexual Abuse and Assualt Examination

A physical examination should be performed in all cases of alleged sexual assault, regardless of the length of time that may have elapsed between the time of the assault and the examination. (See also B. Physical Abuse & Neglect above.)

Sexual Assault Examination Kits and a training videotape are available through the Kentucky State Police. These unisex kits should be readily available to emergency and specially trained medical personnel. Also available are medical advocates to assist victims at the time of the sexual assault examination.

If sexual contact has been within 96 hours, the evaluation shall include evidence collection (Sexual Assault Examination Kit). ( 502 KAR 12:010 Section 3(2)In these cases, an urgent exam should be scheduled (i.e., within a day), especially if the victim complains of physical symptoms or minor injuries in connection with the abuse.

Asymptomatic victims, whose most recent sexual contact was more than 96 hours prior to an examination, can be seen on a scheduled basis, but still as promptly as possible. In these cases, medical discretion is indicated related to the use, or partial use, of the Sexual Assault Examination Kit (i.e., trace evidence may not be present on the victim). Other evidence should be collected, ie, photos, documentation to meet CVCB requirements for compensation for victims.

Evidence should still be gathered by documenting any findings obtained during the medical examination (e.g., bruises, lacerations, etc.), photographs and bite mark impressions (if indicated). Clothing should also be examined for rips/tears or foreign biological material. Powder-free gloves should only be used as powder may interfere with DNA testing. Gloves should be changed frequently to prevent cross-contamination. Statements made by the victim about the assault and complaints of pain should be documented. Some victims may ignore the symptoms that would ordinarily indicate serious physical trauma (e.g., internal injuries sustained by blunt trauma or foreign objects inserted into body orifices) or hoarse secondary to strangulation. Also, there may be areas of tenderness, not apparent at the time of the initial examination, which may later bruise.

When a medical forensic examination is performed, it is vital that the medical and evidence collection procedures be integrated at all times. To minimize patient trauma, blood drawn for medical testing (e.g., blood type, STD’s) should be done at the same time as for evidence collection purposes. When evidence specimens are collected from the oral, vaginal, or rectal orifices, cultures for sexually transmitted diseases should be taken immediately thereafter. In some cases, however, cultures may not be clinically indicated as prophylactic antibiotic treatment should be given even if the patient is asymptomatic.

Kentucky law mandates that sexual abuse and assault victims receive information about available counseling services, testing for STDs and pregnancy, crime victims compensation, etc. A standardized Patient Information Form and the Sexual Assault Examination Certificate are available from.:

Crime Victims Compensation Board  
130 Brighton Park Boulevard 
Frankfort, KY 40601
502/ 573-2290
800/469-2120

For detailed information about sexual assault examination and evidence collection, refer to the following protocols:

Sexual Assault Examination Kits (with instruction sheets) and a training videotape are available through:
Kentucky State Police Central Crime Laboratory
East - West Connector
Frankfort, KY 40602
502/564-5230

Child Sexual Abuse: The Physician’s Role.
Department of Family Practice, University of Kentucky College of Medicine (Rev. 3/93) Lexington, KY.

Sexual Assault/Abuse: A Hospital/Community Protocol for Forensic and Medical Examination
Office of the Attorney General, Victims Advocacy Division (Rev. First Edition, 1990) Frankfort, KY.

U of L Clinical Forensic Medicine
Office of the Chief Medical Examiner, 810 Barret Ave, Louisville, KY 40204

Evaluating the Sexually Assaulted or Sexually Abused Patient,
American College of Emergency Physicians, June 1999.

Morbidity and Mortality Weekly Report, Sexually Transmitted Diseases Treatment & Guidelines, 2002.

Guidelines for the Evaluation of Sexual Abuse of Children: Subject Review
Pediatrics Vol. 103, No. 1 January 1999, pp. 186-191, American Academy of Pediatrics.

D. Documentation (Chart, Photographic)

Readily available and accurate medical records will alert staff to a trauma history which may suggest or document abuse or neglect. Sometimes the patient denies the maltreatment. If however the physician believes or suspects that the presentation suggests maltreatment, the provider’s impression and findings should be documented in the medical record.

The medical record in a case of adult or child maltreatment will be reviewed by other professionals involved in the investigation. In cases which result in court action, the record will likely become a legal document.

The most important part of the record is the clear, comprehensive narrative account of the history and physical exam findings. Reasons:

• Should the case result in court action at a later date, recall can be enhanced with detailed descriptions, photographs, drawings, and other documentation.
• The history from the patient can be important as a record of the questions posed and the patient’s answers (“quote” as much as possible).
• Comprehensive patient examination records (history and physical) demonstrate the examination was thorough. This examination record may keep the patient (and possibly the physician/sexual assault nurse examiner/practitioner) from having to testify, or endure a subsequent examination.
• A legible chart note detailing the patient’s history, physical exam findings, and lab studies should be entered in the patient’s medical chart. Use of assessment forms facilitate and standardize documentation.

Clear and comprehensive records, which include documentation of compliance with standards of care and mandatory reporting requirements, can serve to reduce the risk of criminal and/or civil liability.

1. Chart Documentation

Try to elicit and document:

*type of injury/pain sustained	*duration and progression of maltreatment over time
*sites, size/depth, location, description & approximate age	*healed wounds, scars, fractures, etc. (approx. date of injury)
*any disabilities of the patient	*identity of the alleged perpetrator
*appropriateness of age/development	*any direct or indirect threats to prevent disclosure

Body Injury Map: supplements the narrative description of the patient’s injury or condition. These should be completed and included in the medical record, regardless of whether photographs are taken or not.
Skin Assessment Form: profiles skin condition, especially important for the elderly or debilitated patient (e.g., contusions, welts, punctures, edema, burns, poor turgor, bedsores/decubiti, evidence or physical restraints).

After compiling all data (i.e., patient history, physical exam, evidence collection, photographs, etc.), the physician should review the medical record and document abuse, neglect or exploitation as known or suspected. For example:

• the patient states she has been injured by her partner; or
• the patient states he has been injured but does not state by whom; or
• the patient’s or the patient’s caregiver’s description of how she received the injuries or condition is not consistent with the presenting symptoms or related histories.

2. Photographic Documentation

Health care facilities should have photographic equipment available. Procedures should be established for photographing injuries or conditions of suspected adult and child maltreatment.

Photographic documentation provides a clear graphic depiction of the injury or condition and is “worth a thousand words”.

Understanding of the full extent of a patient’s injury or condition can be enhanced when a detailed, written description or drawing is combined with photographic documentation. This also assists the physician to establish the findings in a comprehensive and professional manner in a legal proceeding.

(Chart): Identify the responding and investigating officer/s in the record.

Consent for Photographic Documentation

Physician protocol need not require separate permission or waiver for consent to photograph or video a patient’s injuries or condition. A refusal to be photographed by the victimized adult patient should be noted in the medical record. The patient should be advised of the importance of photographic documentation and that consent to photograph is not a commitment to prosecute. Further advise the patient that the photographs will remain confidential in the medical record until needed. In extremely rare circumstances, a court order may be obtained for evidence as part of an investigation or prosecution without the consent of the victim.

With respect to child abuse and neglect, the law allows certain information (i.e., photographs and X-rays or other appropriate medical diagnostic procedures) to be gathered as part of a medical evaluation or investigation of a report without the consent of the parent or custodian. See also III. Consent.

Follow-up photographs or video depiction of a patient’s injury or condition may represent the full extent of the maltreatment, more accurately revealing the severity of the injury/condition. These can also help to depict the effects on the patient. If the physician is unable to take follow-up photographs, the patient should be advised to do so with the assistance of the DCBS or local law enforcement, etc.

E. Evidence Collection, Preservation & Release of Forensic Evidence Procedures

1. Evidence Collection & Packaging

Specimens must be sealed in PAPER or CARDBOARD containers to prevent the loss of fibers, or other trace evidence, clothing and other evidence.

NOTE: If containers are plastic, moisture remaining in the evidence items will be sealed in, making it possible for the bacteria to quickly destroy any unstable biological fluid evidence. Unlike plastic, paper ‘breathes’ and allows moisture to escape. Very wet specimens should be air-dried as much as possible before placing in specimen container.

Physical evidence of adult or child maltreatment, not part of the medical record, may include weapons or objects used as weapons, objects removed (e.g., bullets, glass), clothing, bed linens, etc. Collection and proper preservation of this physical evidence should be standard health care facility protocol.

2. Labeling of Evidence

Completely label all laboratory specimens as collected. Verify that specimen containers are properly marked before the specimens are taken from the exam room. It is prudent to label all specimen containers before the examination, if possible.

All specimens and evidence collected must be labeled with the:
patient’s name describe specimen, if necessary, ie “glistening spot on thigh” or “red-brown stain on buttocks”	name of the person collecting the specimen or evidence date and time exact source of the specimen or evidence
Ensure the laboratory specimens are taken expeditiously to the appropriate lab facility.

3. Preserving the Integrity of Evidence

The custody of any evidence collected must be accounted for from the moment of collection until the moment it is introduced in court as evidence. This is to maintain the legally necessary “chain of custody” for evidence. Anyone who handles evidence items should label them with:
his or her initials the date source of the item or specimen	the name of the attending physician the name of the patient
All specimens and evidence collected must be properly sealed, labeled and released per health care facility and law enforcement policy. Receipts of exchange of specimens should be maintained in the chart as part of the chain of custody.

4. Release of Information and/or Evidence

Physical evidence of adult or child maltreatment, not part of the medical record (e.g., weapons or objects used as weapons) objects removed (e.g., bullets, glass, clothing, bed linens, etc.) may be released to law enforcement officials without the consent of the patient and should be released in the course of an investigation. The health care facility should retain for its file, a receipt signed/dated by the investigator that describes the items released.

In cases involving sexual assault, written consent should be obtained from the victimized patient or an authorized third party (e.g., parent, guardian) on behalf of the patient prior to releasing evidence collected as part of a sexual assault examination.

In some cases, a victimized patient may not authorize this release. The patient should be advised that the release is not a commitment to prosecute. Should there still be a refusal or reluctance to authorize the release, advise the patient that the evidence will be stored properly for a designated period of time during which the patient may reconsider the decision. In rare cases, a court order may be obtained for evidence as part of an investigation or prosecution without the consent of the patient.

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