Paper
Sunday, November 13, 2005
Implementing a Comprehensive Computerized Documentation System for Acute Sexual Assault Examinations in the Emergency Department
Rebecca Navarro, MSN, RN, SANE-A1, Dan Qualkinbush, AAS2, Pamella Jahnke, RN, BSN, CEN, SANE-A3, Herbert Blitzer, AB, MBA2, and Agnes Purdie, RN, BSAH4. (1) Center of Hope, Wishard Health Services, Indianapolis, IN, USA, (2) Institute for Forensic Imaging, Indianapolis, IN, USA, (3) Clinical Education and Center of Hope, Community Health Network, Indianapolis, IN, USA, (4) Emergency Department, St. Vincent Hosptial, Indianapolis, IN, USA
| Learning Objective #1: Identify eight components that have been integrated into the comprehensive computerized documentation system for acute sexual assault examinations |
| Learning Objective #2: Identify five benefits of implementing a computerized documentation system for sexual assault examinations in the emergency department |
A computerized documentation system was developed in 2004 to document and track patient information from acute sexual assault examinations conducted by forensic nurse examiners in the emergency department. The computerized documentation system allows forensic nurse examiners to integrate information obtained from a forensic interview with physical exam finding, including injuries documented with digital photographs and bodymapping and evidence collected during a forensic examination, into one document. The forensic nurse can also include other forms such as discharge instructions, consultation notes, and signed patient consents into the computerized document. The completed document with all of these components serves as the patient's medical record. The completed patient medical record is saved on a hospital server and on a compact disc. Care has been taken to protect security of this information and to maintain the privacy of the patient's medical information. The compact disc is available to law enforcement and prosecutors immediately following the completion of the sexual assault examination, if the patient chooses to sign a release for their medical records.
The computerized documentation system has been beneficial for nurses caring for sexual assault patients. It has improved the documentation process through immediate access to photographs of injuries and automated features that facilitate documentation. The system automatically enters information from the medical record into a secured, searchable database. The nurse can access this information to identify trends as a means to improve patient outcomes. The system has also been beneficial for law enforcement officers and prosecutors. It has given them immediate access to information and photographs collected by the forensic nurse examiner, which can be used to enhance the investigation and prosecution of sexual assault cases.
This system was implemented in three hospitals in Indianapolis in Fall 2004. These systems were developed under National Institute of Justice Award number 2002-RG-CX-K004.