Evaluation of documentation practices of sexual assault nurse examiners

Abstract

The California Journal of Emergency Medicine 11:3, July 2001 page 28 Original Research Evaluation of Documentation Practices of Sexual Assault Nurse Examiners Lisa Minshall, MD Department of Emergency Medicine, Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 Mitesh Patel, MD, FAAEM, FACEP P.O. Box 9901 Bakersfield, CA 93389 E-Mail: mitesh@ev l.net Presented at the ACEP annual meeting, Las Vegas, NV, October, 1999; and SAEM Western Regional Research Forum, Redondo Beach, CA February, 1999 INTRODUCTION 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 docu- mentation, Office of Criminal Justice and Planning Form 923 (OCJP 923). This project was undertaken as part of continuing quality assur- ance 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 pro- vides that as part of ongoing quality management activities, the hospi- tal should establish patient care criteria for the management of the sexu- ally assaulted patient and monitor staff performance. Emergency de- partment staff should have ongoing training and education in the manage- ment of the sexually assaulted ~ a t i e n t . We question whether comple- tion 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. METHODS Study Design By drawing from Obstetrics and Gynecology (OBJGYN), emergency medicine (EM), and other relevant literat~re,~ items were l7 identified as essential for comprehensive medical record documentation. These elements were selected due to their frequent citation among the sources. Following literature review, a data collection form was created listing these designated elements, selected as essential for comprehen- sive medical record documentation.Following Institutional Review Board approval, charts of survivors of sexual assault, who presented to the Medical Center between January 1996 and November 1998, were retro- spectively reviewed. Study Setting and Population: The Medical Center is a 180 bed county teaching hospital with an Emergency Department annual volume of approximately 55,000 patients. There are approxi- mately 200 sexual assault victims treated annually. Study Protocol: inclusion criteria included survivor of recent sexual assault (presenting for evaluation with 72 hours of the assault), managed by a SANE, with an age of 16 years or greater. Additionally, chart availability and a completed OCJP 923 standard documentation form were required. Charts in which documents could not be located or that did not meet the above criteria were excluded. Audit of the medical record included not only review of the state mandated OCJP 923 form, but also all pertinent material related to that visit (face sheet, nursing notes, dictated summaries, laboratory slips, etc.). Measurerneizts: The key elements are listed in Table #1 (Es- sential Elements for Comprehensive Medical Record Documentation). Some elements, identified as essential based upon the literature review, have no space for documentation on the OCJP 923 paperwork, and are identified by Italics in Table #I. These inciude historical elements (gen- eral medical history, medication allergies, and current medications), physi- cal examination elements (examination of the oral cavity and bimanual examination), and laboratory and disposition elements (obtaining cul- tures and prophylactic treatment for sexually transmitted diseases, test- ing and prophylaxis for pregnancy, and referral for counseling or other social support measures). Data Analysis: Confidential data from the medical record were transferred onto the data collection form. Data were ana- lyzed using frequencies and percentages. As there is no prior similar review to deternine comparable reference values, and the items selected for audit were considered equally important, 100% compliance was es- tablished as the expected performance standard. RESULTS There were 162 cases of sexual assault over the 36-month re- view period. 127 (78%) charts were available for review, 79 (49%) of which met inclusion criteria. The most common reasons for exclusion were patient age less than 16 years or survivors were not managed by a SANE. Elements reviewed and their frequencies (and percentages) and 95% confidence intervals are listed in Table #2 (Frequency of Documen- tation of Essential Elements). Elements not found on the standardized documentation fonn (OCJP 923) are again depicted in Italics. All but one patient were female, only one male survivor met inclusion criteria. OBI GYM history and pregnancy testing statistics therefore utilize only 78 cases. In addition to the single male survivor, there was one female patient who reported only rectal penetration and subsequently refused examination of the vagina and cervix, as well as the bimanual examination. Therefore, these elements were analyzed for only 77 cases. DISCUSSION Sexual assault is one of the fastest growing violent crimes in the United States, however, it continues to be significantly under-reported. Therefore, data on incidence rates is circumspect at best.16-l8 Statistics from the United States Department of Justice estimate 683,000 sexual assaults annually.19 Importantly, psychological and social support of the survivor, when initiated early, may ameliorate post rape trauma syn- drome through referral and access to long-term care.4 Beginning in 1976, several individual programs were developed nationally utilizing specially trained nurses for the management of survi- vors of sexual assault. These nurses are known as Sexual Assault Nurse Examiners (SANEs) or Clinicians (SANCs). SANEs are specificallytrained to perform evidentiary examinations, provide counseling on pregnancy and Sexually Transmitted Disease (STD) prophylaxis, act as liaison be- tween the survivor and law enforcement, social service personnel, and psychological support systems, as well as provide testimony in a court