In the United States, all 50 states and the District of Columbia require emergency nurses and other healthcare professionals to report the suspected maltreatment of children and older or dependent adults. Fewer states mandate the reporting of intimate partner violence or crimes in general. It is important to know the reporting requirements in the jurisdiction where you work.
Nursing documentation is valuable as forensic evidence and should provide an accurate, unbiased picture of what you hear, see, and smell when providing patient care.
The consistent organization of documentation leads to reliable routines:
o When documenting the patient’s history, include patient statements in direct quotations, whenever possible. In the medical record, patient statements and excited utterances (spontaneous statements made under duress) may be medical exceptions to hearsay in court.
o Avoid sanitizing patient statements or substituting medical terms. Record patient statements verbatim.
o Remain objective in your documentation. Replace terms such as alleged and claimed with reported or suspected. Instead of using the term refused, use declined, said, stated, or reported.
As the first person to come in contact with victims of violence, you must recognize, collect, and preserve the forensic evidence. Keep in mind that the first priority is to ensure that the patient is medically stable.
The Emergency Nurses Association identifies forensics as a part of emergency nursing practice.
Forensic evidence is any tangible item or recorded material that is pertinent to the legal proceedings of the court. It may be tangible, intangible, or trace evidence.
LESSON OUTLINE
Always wear gloves when collecting and handling evidence to prevent contamination.
o Semen may be collected from a prepubescent patient’s body up to 24 hours after the
incident but may linger on clothing longer. Semen may be collected from adult patients many days after an assault and may extend the time for collecting deoxyribonucleic acid (DNA) evidence up to 1 week, depending on the jurisdiction.
o To preserve evidence on clothing, do not cut through damages areas. Place two clean sheets on the floor and lay each piece of patient clothing separately on the top sheet. Collect the top sheet and the sheet from the ambulance stretcher and hospital stretcher. Place each piece of clothing in a separate paper bag, seal it with tape, date and initial the tape, and document the clothes that were collected, including a brief description.
o Assess for stains on the patient’s skin. If detected, swab each stain with a sterile, cotton- tipped applicator that is moistened with sterile water. Air dry the swab, pack it in a clean envelope, write the stain’s appearance and location on the envelope, and initial over the tape.
o If a patient has firearm injuries, place paper bags over the patient’s hands until law enforcement officials can test them for gunpowder residue.
o Collect other debris on a sheet of folded, clean white paper, using a swab or rubber-tipped forceps. Refold the paper and place it in an envelope as you would handle a swab. For minute debris, collect it with transparent tape, place the tape on a glass slide, wrap it in white paper, and then seal and label it.
o Use rubber-tipped forceps to collect bullets or other projectiles. Place each projectile in a separate, small rigid container with sterile gauze and put holes in the lid. Do not label bullet wounds and entrance or exit wounds.
o Handle needles and knives with great care, using rubber-tipped forceps. Package them in cardboard boxes or tubes, glass tubes, or gauze-filled specimen containers with air holes.
A forensic evidence recovery kit should be available in the ED. The kit should contain all the supplies needed to collect and preserve clothing, swabs, debris, projectiles, and other physical evidence along with a procedure manual for evidence collection.
To be accepted in court, physical evidence must be accompanied by documentation that
demonstrates the item’s location and the responsible party at all times. If the chain of custody is not maintained or documented, an entire case may be lost. Each time the evidence changes hands, such as turning evidence over to a police officer, a receipt must be generated and signed by both parties.
Such a paper trail demonstrates a continuous chain in the custody of the evidence, and each individual who has contact with the evidence becomes a link in that chain.
o To accurately document the location of injuries or physical evidence, include a body diagram or map and photographs along with the written or computerized nursing note.
o On a body diagram, clearly include the location and type of injury or evidence collected as well as a brief description.
LESSON OUTLINE
o Photographs should not replace body diagrams because they may be lost or poorly representative. Take a series of photographs, following the rule of thirds. To begin,
photograph the front of the patient from 6 feet away. Next, photograph the patient’s injury one-third the distance (4 feet away) and finally take a close-up at one-third the distance (2 feet away) with and without a scale, such as a ruler or penny.
Use the correct medical-forensic terms when describing wounds.
o Bruises result from blunt or compressive forces that damage blood vessels, which lead to bleeding under the skin or in another organ.
o Ecchymosis is usually caused by a slow, hemorrhagic blood leak into the skin due to aging, medications, or a medical or hematologic disorder.
o Lacerations result from the tearing or splitting of the skin or another organ by a blunt or shearing force.
o Cuts or incisions are caused by cutting the skin or another organ with a sharp object, such as a knife or scalpel.
o Ligature strangulation takes place when a cordlike object is wrapped around the neck and tightened. Common ligatures include ropes, electrical wires, telephone cords, clothes, torn sheets, and even very long hair. Ligature strangulation usually leaves a ligature mark that is a combination of a compression bruise and an abrasion.
o Manual strangulation occurs when the assailant compresses the patient’s neck using some part of his or her body, such as the hands or arms (as in a headlock). Visible injuries to the neck after manual strangulation can be rare.
A loss of bowel and bladder control is common in patients strangled to unconsciousness or near-unconsciousness.
Close supervision and monitoring for 24 hours is recommended while watching for respiratory complications.
PRECEPTOR EXERCISES
Discuss the following questions with your preceptor: