determination about forensic evidence collection, remember that the details of the event can become more specific over time The provider should document the history source, a description of the event, and use quotations when documenting the exact words from the patient’s disclosure when possible Document the witnesses present during the interview in the medical record Perform and document a complete physical examination including all injuries sustained Perform the examination with a chaperone, regardless of the gender of the patient or provider This chaperone should be a trained member of the medical staff who can assist in examination procedures and serves as an unbiased witness A parent or another familiar adult can remain with the child to provide support and comfort Distraction techniques, pain control, anxiolysis, or sedation may be required in some situations The anogenital examination includes careful inspection of the penis and scrotum in males, the mons pubis, the labia, vaginal opening, and hymen in females, and the anus in all patients A speculum or bimanual examination is rarely required in adolescent patients It may be indicated if there is significant vaginal bleeding, or concern for a retained vaginal foreign body It should be avoided in prepubertal patients Photo documentation of all injuries is recommended It is useful to photo document a normal genital examination as well, to avoid risk of not detecting subtle, potentially forensic findings While a colposcope provides magnification for optimal visualization and high-quality photo documentation, there are other digital health advances that EDs are using that may obviate the need for this equipment In specific, digital photograph systems that are integrated with the electronic health record are being used and provide excellent photo documentation with little training required to provide diagnostic quality images for peer and quality improvement review Regardless of the equipment and system used, the important caveat is: (1) all forensic examinations include photo documentation that is conducted in a secure, protected fashion; and (2) photo documentation is of diagnostic quality to adequately represent the examination and potential findings Written documentation detailing the examination must be included in the medical record Of note, urgent physical examination is not required if the assault occurred >72 hours prior to presentation, unless the child/adolescent has ongoing symptoms including but not limited to, significant abdominal pain or genital pain or other complaint, bleeding, or discharge If that is not the case, it may be preferable to refer the child/adolescent for an outpatient medical evaluation with a specialist in child sexual assault As stated previously, the vast majority of children have normal anogenital examinations, in part due to the rapid healing of the mucosa as well as the nonviolent nature of most child sexual abuse A normal physical examination does not rule out sexual assault Many studies have documented the examination findings that are indicative of sexual abuse, including lacerations of posterior aspect of the hymen and posterior fourchette, ecchymosis of the hymen, or perianal lacerations Other acute genital injuries are concerning, though not diagnostic of sexual abuse, and include bruising or lacerations of the vulva, penis, scrotum, or perineum These injuries can be caused by accidental mechanisms, but the history provides the context for interpretation of these types of injuries Management/Diagnostic Testing Acute Medical Management Medical or surgical treatment of associated injuries follows standard procedure with immediate consultation by specialty services as indicated (Chapter A General Approach to the Ill or Injured Child ) During initial medical evaluation and stabilization, make all reasonable attempts to preserve potential evidence, if possible Avoiding cutting through holes found in clothing; collect all clothing and place in paper bags and keep it with the patient until chain of custody can be confirmed Avoid washing away potential DNA evidence The management of serious coexisting injuries or other acute medical conditions takes precedence over preservation of forensic evidence If needed, a forensic examination can be completed in the operating room, prior to prepping the injured area for surgery, and in concert with the surgeon managing the serious injury Weighing the risk/benefit of forensic evidence collection to providing medical/surgical treatment is a collaborative decision of the treatment team Forensic Evidence Collection Studies in prepubertal children have shown that the yield of forensic evidence collection diminishes rapidly with time and is low for children presenting more than 24 hours after assault However, a few recent studies have documented few findings of DNA evidence outside of the 24-hour window in prepubertal victims and these authors postulate that as the field of DNA technology continues to advance, consideration of collection outside of the current time recommendations should be considered in some cases For adolescent patients presenting within 72 hours of assault, the collection of forensic evidence has significantly high yield Upon ED entry, victims should be advised not to undress, eat or drink, and avoid urination or defecation if possible The patient’s clothes should be stored in individualized and separate paper bags as a significant amount of forensic evidence has been retrieved from linens and clothing Tables 127.2 and 127.3 provide details about forensic evidence collection TABLE 127.2 FORENSIC EVIDENCE COLLECTION KIT Use a standardized forensic evidence kit that meets the requirements of the police jurisdiction in your location The exact content of the kit may vary based on the jurisdiction but in general most kits will include the following items: Container (box) in which most of the evidence will be placed Form for obtaining authorization to collect and release evidence and information to law enforcement Checklists to guide history taking, physical examination, and specimen collection Evidence seals and biohazard labels Form for documenting chain of custody Labels for identifying information and evidence Paper bags to hold clothing and other bulky items that not fit in container a Envelopes or other containers for collection of debris, nail scrapings, hair, etc Several cotton swabs for collection of specimens and glass slides b Tubes or containers for collection of secretions Buccal swabs and/or blood sample tubes for blood typing and DNA analysis Combs for scalp and/or pubic hair combings Instrument for obtaining nail scrapings and/or cuttings Gauze or swabs for saliva sample Other items that may be needed but that are not necessarily in the kit include: Camera or colposcope system for photographic documentation Alternate light source Forensic swab dryer and rack a Plastic bags should not be used for evidence collection because they retain moisture which can lead to degradation of evidence b Slides may be included if the forensic laboratory prefers that the swabs be made into slides at the hospital Other forensic laboratories may prefer that the swabs be placed in envelopes or containers without slides being made