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Question by jaish8904: Some advises on medical record?
A policewoman escorted a 20 year old girl who was a victim of sexual harassment. A doctor at the emergency department examined her.

1) what the doc should do to document the results of the examination?
2)The attorney requests the doctor to give expert witness at a trial. What the doc should do if requested to stand in trial?

Best answer:

Answer by greydoc6
Many hospitals have a written protocol on how to handle these situations. If the woman has been sexually assaulted, the ideal situation would be to have a rape counselor see her prior to the exam, and to be present during he exam. The physician would examine the victim for signs of assault including bruises, laceration, defensive wounds, etc. He or she would ask to do a vaginal exam for signs of trauma and seminal fluid. Seminal fluid may be obtained and saved for DNA analysis. After treating the patient, the physician needs to make a complete and accurate account in the medical record. The doctor usually needs to review the record before giving testimony at trial.

Edit: get permission from the patient to take photographs of any wounds to document for later testimony.

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