Evaluation of Documentation Practices of Sexual Assault Nurse Examiners
نویسندگان
چکیده
There is scant published data critically evaluating the quality of the medical record generated by Sexual Assault Nurse Examiners (SANEs) in the documentation of the evaluation and treatment survivors of sexual assault receive while in the Emergency Department. For all adult sexual assault survivors undergoing evidentiary examination, this State mandates a standard recording tool be used for medical-legal documentation, Office of Criminal Justice and Planning Form 923 (OCJP 923). This project was undertaken as part of continuing quality assurance measures by comparing medical record documentation practices of our Medical Center SANEs to the standards set forth in the medical literature. Internal reviews by other SANE or protocol-based programs have resulted in individual institutional protocol revisions and policy changes in an effort to continually improve the quality of care provided to survivors of sexual assault.' The 1995 ACEP policy statement provides that "as part of ongoing quality management activities, the hospital should establish patient care criteria for the management of the sexually assaulted patient and monitor staff performance. Emergency department staff should have ongoing training and education in the management of the sexually assaulted ~ a t i e n t . " ~ We question whether completion of a state mandated medical-legal recording tool by the SANE is sufficient to meet the medical needs of patients who present to the Emergency Department with the complaint of sexual assault.
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