4.4.2.3 Patient Assessment and Urine Collection

Obtain the patient’s vital signs. If they are abnormal, recheck and take appropriate action.

Injuries causing pain or serious discomfort should be treated before starting the sexual assault exam.

If a drug-facilitated sexual assault is suspected, urine needs to be collected and preserved.

Urine may be collected up to 96 hours post-assault. Have the patient urinate into a tamper-resistant, urine specimen container that can be securely sealed. Label the container with the patient’s information.

Obtain a urine specimen for a pregnancy test on all female patients of childbearing age. If the specific gravity of the urine is < 1.015, a serum pregnancy test should be sent to the lab to ensure accurate results.

Perform a head-to-toe assessment for evidence of trauma to the body, and investigate any complaints of pain, working your way literally from head to toe.

Pay attention to any area of concern, based on the mechanism of injury and the patient’s history of the assault.

Document all injuries. Measure and describe all injuries, indicating their locations. Use the ‘Body Map’ that is part of the ‘Sexual Assault History Form’.

If possible, photographic documentation of injuries is strongly recommended.