file

pdf

School

Western Governors University *

*We aren’t endorsed by this school

Course

SANE

Subject

Medicine

Date

Apr 3, 2024

Type

pdf

Pages

38

Uploaded by ProfessorRaven732

Report
DOCUMENTATION OF THE EXAM
OBJECTIV E Describe methods for documenting the medical forensic examination Discuss the elements of documentation required in the medical forensic examination Describe common issues that impact a well-documented exam Discuss how the medical-forensic documentation will be used by other disciplines involved, including at trial
METHODS FOR DOCUMENTING THE EXAM Written Electronic Body diagrams Photography Videography
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
DOCUMENTATION FORMS IN THE NC SAECK
C O N S E N T • Legal caregiver/guardian • Assent by older child/teen • Make sure the caregiver and child understand what you are doing with the SAECK • You do not analyze it at the hospital • Caregiver and patient (age appropriate) understand what the exam entails
CONSENT IN SPANISH Document • Who assisted with interpretation • Who was in the room during the evaluation
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Step 2
A history was obtained from Kira’s mother, Katie Smith, out of the presence of Kira. Ms. Smith stated she noted blood in Kira’s underwear when she assisted her in removing her clothes for her bath tonight around 7:00pm. Ms. Smith stated she asked Kira if she had hurt her vagina. Ms. Smith stated Kira told her that “Brandon” put his finger in her vagina and it “really hurt.” Ms. Smith stated Brandon Thomas is a 17 year old boy that babysits until she can get home from work. Brandon babysits Monday through Thursday from 4 to 6pm. Brandon babysat Kira today and Ms. Smith arrived home at 6:00pm and relieved Brandon. Kira reported no other bodily contact between her and Brandon. Kira provided a history in the emergency department of Brandon putting his finger in her vagina and it “hurt” and “blooded.”
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
3/12/2022 Between 4-6:00pm Patient’s home 1 Caucasian Male X X Unknown X X X X X X X
X X X X X X X X X X X
M E D I C A L H I S T O R Y • The forms in the NC SAECK are not comprehensive. • You may want to add to these forms or develop your own. • These forms are more adolescent/adult specific • Some have developed forms for the prepubertal child and the adolescent/adult.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
98.3F (Tymp) 96 16 98/56 X With ALS
N/A N/A N/A Pneumonia age 3 years with 3 day hospitalization NKDA None reported Multivitamin every day N/A None reported. Mother reported no history of STIs pre or during pregnancy.
SMR 1. No redness, swelling, bruising, abrasions, lacerations, cuts, lesions. No bleeding or discharge noted from vaginal opening Not visualized Not examined No anal laxity, lesions, bruising, abrasions, lacerations, cuts, bleeding, discharge F. Hymen: Unestrogenized. Posterior rim smooth and without deep notches or complete transections. G. Posterior Fourchette: Tear at 6:00 with drop of blood noted.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
M E D I C A L H I S T O R Y F O R M – P A G E 2
X X X X
Beacon Child Medical Evaluation Clinic Beacon Office will call to make appointment
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Step 11 Anatomical Drawing
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Supine Position Prone Knee Chest
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
No pubic hair Labial Swabs Anal Swabs Prepubertal Anal Swabs collected No concerning history
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Prepubertal Young child
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Options depend on program policy
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
DISCHARGE INSTRUCTION S • Medical Examination • Forensic Evidence Collection • Photographs • Diagnostics/Results • Medications given • Prescriptions provided What was done at the visit: Follow-up instructions
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
MOST COMMON ISSUES IN COURT Handwritten documentation illegible Inconsistency in documentation Failure to use quotes Forgetting important details (if it isn’t documented, it wasn’t done) Incomplete documentation Labeling with incorrect patient demographics Photographs are not clear or do not depict areas identified as concerning Yes, you can add an addendum, just make it clear why you are adding the addendum, the date, the time, your signature
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help
QUESTIONS
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
  • Access to all documents
  • Unlimited textbook solutions
  • 24/7 expert homework help

Related Documents

Hand-off Report _Final(1).docx
NRSG 617 Policy and Politics Unit 4 PAPER_ Carver.pdf
IHP 620 milestone one (1).docx
module 4 discussion response.docx
peer-reviewer-survey.docx
chemo4.docx
Paper 1.docx
HP353 Class Visit #3 (2) (1) (2)(1)(1) (1).pptx
Institution_reserch_CHIU (1).docx
Fat Duck Case Study updated.docx
5366 ROL syntesis discussion.docx
Government-Sponsored Healthcare Programs CH 3 RQ.docx