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MEDICAL RECORD SEXUAL ASSAULT FORM Print Name or Use Patient Plate. HISTORYDATE OF VISITTIMESignificant past medical history: Approximate Time of Attacks patient pregnant?LMPMedicationsAllergies Date
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How to fill out medical record sexual assault

01
Start by gathering all necessary information for the medical record, such as the patient's personal details, date and time of the assault, and any relevant medical history.
02
Begin the medical record by stating the purpose of the documentation and the reason for conducting the examination.
03
Document the patient's statement regarding the assault in a clear and detailed manner, using their own words whenever possible.
04
Conduct a thorough physical examination, documenting any injuries, signs of trauma, or physiological symptoms experienced by the patient.
05
Record any laboratory tests or diagnostic procedures performed in relation to the sexual assault case, including the results.
06
Document any medications administered or prescribed for the patient, along with the dosage and instructions.
07
Include any forensic evidence collected during the examination, such as photographs, swabs, or clothing samples.
08
Write a summary and assessment of the findings, including any immediate treatment or referrals.
09
Sign and date the medical record, ensuring it is legible and identifiable as your own.
10
Safely store the medical record according to the guidelines and regulations in your region.

Who needs medical record sexual assault?

01
A medical record of sexual assault is needed by various individuals and organizations involved in the investigation and prosecution of such cases.
02
These may include law enforcement agencies, forensic laboratories, attorneys, and court officials.
03
Additionally, the medical record may be used by healthcare professionals providing ongoing care and support to the survivor of the assault.
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Medical record sexual assault refers to documenting and reporting cases of sexual assault in a patient's medical history.
Healthcare providers are required to file medical record of sexual assault cases.
To fill out a medical record of sexual assault, detailed information about the incident and the patient's condition must be documented.
The purpose of a medical record of sexual assault is to provide an accurate account of the incident for legal and medical purposes.
Information such as the nature of the assault, injuries sustained, patient's statements, and any evidence collected must be reported on the medical record of sexual assault.
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