Forensic Evidence Collection in Kentucky Nursing CE Course

Standards of Forensic Nursing Practice

Forensic nursing uses the Quality-Caring Model as its theoretical framework, as originally described by Duffy and Hoskins (2003). The IAFN developed standards of practice based on this relationship-based model. The standards of forensic nursing practice are as follows:

• assessment
• diagnosis
• outcomes
• planning
• implementation
• coordination of care
• health teaching and health promotion
• evaluation (ANA & IAFN, 2017; Robinson, 2022)

Assessment

As the first standard of forensic nursing, assessment includes collecting demographic data and information about the patient’s physical, emotional, psychosocial, cognitive, sexual, and developmental status. The assessment helps the nurse understand the patient’s needs and preferences and develop a comprehensive understanding of the situation (ANA & IAFN, 2017; Robinson, 2022).

Diagnosis

The nurse will analyze the data obtained to determine an actual or potential diagnosis. The nurse will use clinical findings to prioritize problems with the patient. Diagnoses will be used to determine appropriate testing and follow-up (ANA & IAFN, 2017; Robinson, 2022).

Outcomes

            The nurse will work with the patient and multidisciplinary team to identify expected outcomes. Each situation will have unique outcomes determined by the patient’s status and their response to the situation. All outcomes must be measurable, reviewed, and modified based on the patient’s response. An example of an appropriate outcome is the need for the patient to verbalize an understanding of the risk and prevention of pregnancy from the assault (ANA & IAFN, 2017; Robinson, 2022).

Planning

            The nurse will work with the patient and multidisciplinary team to develop a plan of care to preserve and restore the patient’s health. The plan will be based on the patient’s needs and consider the potential short- and long-term effects of violent assault. An example of an appropriate plan is scheduling counseling for the patient and referring the patient to a dedicated fund for financial assistance of individuals who have experienced violence (ANA & IAFN, 2017; Robinson, 2022).

Implementation

The plan is implemented in collaboration with a multidisciplinary team and will be documented appropriately. Health teaching and promotion should also be incorporated. The examiner must be able to identify what is needed for a healthy and safe environment for the patient while identifying any appropriate disease prevention interventions required, such as vaccinations or medication prophylaxis. The patient’s developmental level, readiness to learn, culture, and socioeconomic status should be considered when individualizing the implementation. The examiner will anticipate the patient’s needs to decrease the risk of negative health outcomes (ANA & IAFN, 2017; Robinson, 2022).

Evaluation

The final standard of practice is evaluation. The examiner will assess the plan of care throughout the process, revising goals and outcomes as needed. The SANE will consider whether their plan is patient-centered, effective, efficient, safe, and timely (ANA & IAFN, 2017; Robinson, 2022).

Physical Examination and Interview of the Forensic Patient

In 2016, the state of Kentucky started requiring hospitals with an emergency department to have a qualified physician or other trained medical professional available on call at all times to examine individuals who experience sexual violence. The examination must be performed according to the statewide medical forensic protocol. Kentucky has guidelines for collecting, packaging, storing, transferring, and destroying samples and evidence taken during a forensic exam (COK, 2025a, 2025b). These include:

• determining storage location, which is usually the facility where the samples are collected
• collection and packaging as outlined in KRS 216B.400 and 502 KAR 12:010, and per the instructions in the SAK, including
• basic treatment
• appropriate laboratory tests
• options for treatment of sexually transmitted infections (STIs), pregnancy, medical, and psychiatric problems (pregnancy counseling shall not include abortion counseling)
• information on available crisis intervention and mental health services
• secure storage to protect the chain of evidence
• removal of samples from secure storage if the individual who experienced sexual violence authorizes their release to law enforcement, 1 year has elapsed, or the individual authorizes the samples’ destruction
• a Rape Crisis Center advocate must be notified of the patient’s arrival, and their presence during the examination should be offered to the patient per 502 KAR 12:010 (COK, 2025a, 2025b)

In Kentucky, adults who experience sexual violence can choose whether to report the incident to law enforcement without being denied examination and treatment. Assaults involving adults should only be reported with the adult patient’s authorization unless the adult is considered vulnerable or unable to manage their own resources, carry out the activities of daily living, or protect themself due to mental or physical dysfunction. If an adult elects to report the incident, the hospital must notify law enforcement within 24 hr (COK, 2025a, 2025b; Kentucky Association of Sexual Assault Programs, 2018). If an adult chooses not to report a violent crime to law enforcement, the health care professionals must provide information about:

(a) Length of time samples will be stored (1 year);

(b) Whom the patient may contact to file a report or authorize the release of samples; and

(c) Whether the samples will be automatically destroyed or transferred for extended storage if the patient does not request the release of samples to law enforcement within the specified period.

Samples may be destroyed after the requisite one-year storage period if the assault has not been reported. The individual who experienced the violence should be notified 14 days before sample destruction. Suspected abuse or neglect of a patient under the age of 18 must be reported immediately to the Cabinet for Health and Family Services, a local or state law enforcement agency, or the Commonwealth’s attorney (COK, 2025a, 2025b; Kentucky Association of Sexual Assault Programs, 2018).

A Victim-Centered and Trauma-Informed Approach

Sexual violence is a traumatic event that negatively affects overall health and well-being. A victim-centered approach consistently focuses on the patient, including their specific needs and concerns. This technique should be practiced by the entire multidisciplinary team (including medical providers, law enforcement, victim advocates, social workers, etc.). This approach aims to convey compassion and empathy and avoid judgment. Trauma-informed care starts with understanding the source of the trauma endured by the patient. Sources of trauma will include the recent assault but may also involve previous experiences of abuse and historical trauma. Members of the health care team should seek to understand potential connections between the patient’s symptoms (and behavior) and their trauma history. Trauma-informed care also recognizes the trauma’s effect on the patient’s family and friends, including their ability to care for the patient. A trauma-informed approach requires attending to the patient’s emotional safety as diligently as their physical safety. The goal of care is to reduce the risk of further injury (i.e., retraumatization) while recognizing the patient’s recent neurobiological trauma (Buchanan, 2026; Feeney et al., 2025; London et al., 2026; NIJ, 2017; OVW, 2016).

According to the Substance Abuse and Mental Health Services Administration (2017), retraumatization is defined as “stress reactions experienced as a result of a traumatic event when faced with a new, similar incident” (p. 1). The health care team should use language and terminology that is thoughtful, deliberate, and easy to understand. Nurses should provide culturally sensitive care and use self-identifying gender preferences and trauma-informed practices when discussing assigned sex at birth (Buchanan, 2026; Feeney et al., 2025; NIJ, 2017; OVW, 2016). Human behavior is affected by the neurobiological changes that occur during trauma. For example, a traumatic event will often trigger dissociation, a reduction in the functioning of the prefrontal cortex (the brain’s center of logic and rational decision-making), and a fight, flight, or freeze response (Sexual Assault Kit Initiative, n.d.). There is no expected or “normal” behavior after a sexual assault. Some behaviors that may be observed in a patient following a sexual assault are:

• blunt or flat affect
• agitation
• fidgeting or poor eye contact
• somnolence
• difficulty remembering details
• difficulty with why questions
• indecisiveness
• emotional lability (American College of Obstetricians & Gynecologists, 2025; Keith & Skidmore, 2026; Robinson, 2022)

HCPs must inform patients about each step of the examination before it occurs and offer choices whenever possible to reinforce the patient’s self-determination and autonomy. Patients should be given ample time to answer questions, with breaks offered if they appear overwhelmed. When in doubt, the examiner should ask the patient what they need to feel safe. Challenging and sensitive topics must be discussed honestly, respectfully, and sensitively to provide appropriate care and prevent further harm. It is best practice to start with less stressful questions about general health and explain the rationale for each question. Before discussing the incident, the examiner should explain that understanding what occurred is necessary to guide treatment and evidence collection. Questions should be open-ended, and the examiner should avoid questions that begin with “why.” Patients may have greater difficulty recalling details immediately after a sexual assault, especially if they have not slept. Because trauma can contribute to conditions such as posttraumatic stress disorder and acute stress disorder, the patient’s mental and physical needs should be addressed. A sexual assault (or victim) advocate should be provided whenever available to enhance the patient’s comfort. The advocate’s role is to provide counseling and support services to individuals who experience sexual or other violent crime. Patients with limited English proficiency and patients with vision or hearing disabilities should be offered interpreters or appropriate communication aids to support effective communication (Buchanan, 2026; London et al., 2026; OVW, 2024; Sachs et al., 2026).

The patient should be counseled on the potential benefits and consequences of reporting the assault to law enforcement in cases where reporting is not mandatory (adult patients). The patient decides whether to report the incident to law enforcement; the nurse should support their decision-making by answering their questions and providing objective information. The sexual assault advocate may also provide valuable support and insight into the legal processes and procedures, should they decide to report the incident. Some jurisdictions have alternative methods for reporting. As with other facets of the process, the reporting should be centered on the individuals who experienced the violence. The medical exam can be done whether the patient has decided to report the incident immediately or not. The evidence can be submitted later if the patient chooses to report (Buchanan, 2026; London et al., 2026; OVW, 2024; Sachs et al., 2026).

Before the Examination

Before beginning an examination, verbal and written consent must be obtained. In the case of an adolescent or pediatric patient, this consent may need to be obtained from the legal guardian, depending on the local jurisdiction’s regulations. Informed consent should include an explanation of the purpose of the samples, how the samples/kit may be used, and that consent can be partial (certain parts of the exam) and withdrawn at any time. If possible, the examiner should also include time frames, processing procedures, and how the patient may be notified regarding test results. A forensic examination should occur in a quiet, safe environment that offers the patient privacy. The patient assessment should not be interrupted by the outside environment. Recommended equipment and space include the following:

• an image-capturing system, such as a digital camera (personal photography equipment or phones should not be used as the chain of custody cannot be maintained on personal devices)
• a colposcope or other magnification system
• an SAK and associated forensic medical documentation forms
• a DFSA or toxicology testing kit (DFSA urine should be frozen or refrigerated to maintain the chain of custody)
• paper bags
• evidence tape
• marking pens
• indicated personal protective equipment
• a drying area for evidence
• locked and secured temporary storage space for any evidence awaiting release to law enforcement (Buchanan, 2026; London et al., 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2024)

The forensic medical examination, including STI management and prophylaxis of pregnancy or HIV infection, should be free of charge. The Crime Victims Compensation Board covers this cost. However, additional medical treatment may incur a cost. Adult patients should also be aware that statements made during their exam and interview are not privileged and may be disclosed (COK, 2025a, 2025b).

Adult/Adolescent Protocol

Adults, including older adults, will have similar protocols regarding evidence collection and physical examination. Adolescent patients should receive their examination by a certified forensic professional, such as a SANE (Bechtel & Bennett, 2026; Buchanan, 2026; London et al., 2026; NIJ, 2017).

Initial Presentation

Adult and adolescent patients who present with reports of an assault have the right to receive a forensic medical assessment. These patients should be triaged as a medical emergency and assigned a 3 or above designation on the 5-tier emergency room triage system. If they are not already present, the forensic examiner and a sexual assault advocate should be notified of the patient’s arrival. In the meantime, an HCP should evaluate the patient as soon as possible. The patient should be escorted to a private waiting area, and staff should confirm that the patient is safe and the suspect is not present. Speaking to the patient alone is often necessary to obtain this information. The examiner should assess the patient’s pain level and ask about any bleeding. Once the patient is medically stable, a forensic medical assessment should be offered. Until the exam is completed, the patient should be advised to avoid using the restroom, washing, changing clothes, smoking, eating, or drinking when feasible. If the patient must use the restroom and DFSA is suspected, urine should be collected in the prepackaged DFSA specimen cup included in the SAK, and the patient should avoid wiping until evidence has been collected. The chain of custody must be maintained for all specimens (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-b; London et al., 2026; NIJ, 2017).

Forensic Examiner/Nurse

• The forensic examiner should obtain informed consent after introducing themselves to the patient and explaining what to expect from the forensic exam. The examiner should determine if the patient wishes to report the incident to law enforcement. For older adults (over the age of 65), reporting is typically mandatory. The medical assessment may occur before or during the forensic sexual assault assessment and varies depending on facility policy. The examiner should obtain a detailed description of the incident. Along with a verbatim description of the assault, the examiner should document the following:
• all persons present during the patient history and assessment
• the time, date, and location of the assault
• any physical contact and penetrative acts by the perpetrator
• any possible injuries to the suspect
• the use of lubricant, including saliva
• any patient actions between the assault and arriving at the facility (e.g., oral care, changing clothes, vomiting, smoking, swimming, douching, or bathing)
• the presence or absence of menstruation and the use of a menstrual cup or tampon during the assault or forensic assessment
• the use of a condom or other barrier
• the occurrence of ejaculation by the patient or suspect
• any weapon or physical force used (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-b; COK, 2025a, 2025b; London et al., 2026; NIJ, 2017)

The steps for evidence collection and packaging include the following (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-b; London et al., 2026; NIJ, 2017):

• Obtain written consent/authorization.
• Apply powder-free gloves when handling kit contents, changing gloves between each swab.
• The examiner should inspect the SAK’s integrity before opening the sealed kit.
• The examiner should not cough or sneeze over the evidence.
• Each item of clothing should be individually sealed in a paper bag. The patient’s underwear should go in the SAK.
• A prepackaged DFSA specimen kit should be utilized to collect urine if appropriate. Indications for this include unexplained memory loss, loss of consciousness, nausea, vomiting, and dizziness.
• Place blood or urine DFSA samples in a sealed and labeled biohazard bag that is then placed into a sealed and labeled cardboard box. Urine should not be placed in the SAK to maintain the chain of custody.
• When a prepackaged DFSA kit is unavailable, the examiner may use one gray top tube of blood and a dirty (i.e., not sterile or clean-catch) urine specimen.
• Swabs should be placed directly into swab boxes. All other wet evidence (e.g., clothing, underwear, etc.) should be air-dried before packaging, if possible. When air drying is not possible, wet evidence should be refrigerated. Law enforcement can take specimens for drying.
• Envelopes that contain evidence should be sealed with self-adhesive labels or tape, not saliva.
• All evidence should be sealed and labeled with the date and time of collection and the examiner’s initials.

Pediatric Protocol

If a pediatric patient presents following a sexual assault, they should have an assessment regardless of when the assault occurred or what the child states occurred. A trained forensic professional should evaluate all children. Forensic experts are trained to ask the most appropriate questions to obtain a history. Forensic medical assessments completed by a qualified expert can yield additional medical findings, new information, information regarding STIs, and the presence of other individuals who may have been affected or attacked. When a forensic professional is unavailable, another HCP can complete the forensic medical history, assessment, and acute evidence collection. The patient should then be referred to a forensic expert for additional assessment when possible (OVW, 2016). HCPs in Kentucky should refer to the Kentucky Medical Protocol for Child Sexual Assault/Abuse Evaluation developed by the Sexual Assault Response Team Advisory Committee for additional guidance (COK, 2025a, 2025b; Kentucky Association of Sexual Assault Programs, 2024).

Initial Presentation

Pediatric patients presenting to the emergency department with reports of sexual assault should be triaged at a level 2. As with an adult or adolescent patient, the patient should be seen as soon as possible, stabilized, and a forensic medical exam offered. The care leading up to the forensic medical exam will be the same as for an adult or adolescent patient (OVW, 2016).

Forensic Examiner/Nurse

The forensic examiner will obtain informed consent after introducing themselves to the patient and explaining what to expect. Verbal assent should also be sought from pediatric patients, as they can refuse all or part of the exam. If the patient refuses, the examiner should try to discern what is preventing them from assenting. An adjustment or slight change to the process or the current environment may make the patient feel more comfortable. If the patient continues to decline, they should be allowed to return at another time for assessment. If the patient returns within 120 hr of the assault, an SAK can still be obtained. All cases of suspected sexual assault of a child under 18 must be reported to law enforcement. As mentioned above, the medical assessment may occur before or during the forensic sexual assault assessment, depending on facility policy. The examiner should obtain a detailed description of the incident and document the same information as with an adult exam. Evidence is collected following the same procedure as adult patients (OVW, 2016).

SAK

            SAKs should meet or exceed minimum national guidelines. Standardizing kits within a jurisdiction and across a state or territory is recommended. In Kentucky, the Kentucky State Police Sexual Assault Evidence Collection Kit is recommended if the incident occurred within the last 96 hr. The kit information should then be entered into the sexual assault tracking portal per KRS 16.132 (COK, 2025a, 2025b). Regardless of how kit contents vary, every kit should meet the following minimum guidelines:

• a container with a blank label for identifying information and documenting the chain of custody (most items will be placed in the container after being dried, packaged, labeled, and sealed, although bags should be provided for bulky items that will not fit in the container)
• an instruction sheet or checklist that guides the examiner in collecting evidence and maintaining the chain of custody
• a set of forms that facilitate evidence collection and analysis, including patient authorization to collect and release evidence, the medical forensic history, and anatomical diagrams
• any materials necessary for collecting and preserving the following evidence:
• clothing, underwear, and foreign material dislodged from clothing
• foreign material on the patient’s body, including debris and dried secretions
• fibers, loose hairs, fingernail cuttings or scrapings, various types of swabs
• plucked or pulled hair
• vaginal and cervical swabs
• penile swabs
• anal/perianal swabs
• oral swabs
• body swabs
• known blood, saliva, or buccal swab for DNA analysis and comparison (Buchanan, 2026; Mailhes et al., 2023; OVW, 2024)

Swabbing and Evidence Collection

Forensic evidence deteriorates with time, so evidence must be collected as soon as possible. Evidence should be collected whether the patient is seen directly after the assault or days later, even if the patient has showered, douched, or swum. Sexual assault samples can be taken for five days or longer postassault. As technology advances, that period expands and, in some instances, can be up to nine days. When swabbing a patient, it is best practice to collect evidence using two swabs from each site. Before swabbing each site, the process and reason for swabbing should be explained. Photographs can be taken at this time per facility protocol. Taking photographs during evidence collection prevents the patient from having injured areas exposed multiple times. It also allows photographs of the evidence and injuries before they are disturbed or altered. The procedure for collecting swabs and evidence includes the following steps (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-b; Mailhes et al., 2023; NIJ, 2017; OVW, 2024):

• Moisten swabs with sterile water when necessary or directly before evidence collection. Swabs can be air-dried or placed in the swab box without being dried.
• Prevent cross-contamination with strict practices such as changing gloves between sites and not coughing over swabs.
• Seal swabs from left and right body parts in the same envelope, but in different boxes. For example, swabs from the left and right breasts are placed in separate boxes and sealed inside the same envelope.
• Examiners should wear gloves and masks during evidence collection. However, using a mask by the examiner may cause stress to a patient who has recently experienced a sexual assault. The examiner will need to use judgment on a case-by-case basis regarding whether wearing a mask is the best option.
• The purpose of the oral swab is to recover foreign DNA. Foreign DNA degrades quickly in the oral cavity. If oral penetration is suspected or the patient is unconscious, oral swabs should be collected as soon as possible.
• The oral swab collection process includes putting on new gloves and using two swabs to swab the inside of the patient’s mouth around the gum lines. The two swabs should be sealed together in a labeled swab box and placed in the oral swab envelope.
• The known DNA buccal swabs/Whatman Flinders Technology card is used to determine the patient’s DNA for comparison to other samples. The swabs for foreign DNA should be obtained first. The examiner should wait 15 to 20 min, have the patient swish their mouth with water, and then wait another 15 to 20 min. The patient’s known DNA should then be collected, sealed, labeled, and placed within the SAK as directed.
• Any matted head hair should be clipped or swabbed with lightly moistened swabs. Depending on facility policy and kit instructions, reference samples should be collected by cutting or pulling/plucking hair (patients who are deceased ONLY). As with previous samples, these should be sealed, labeled, and placed in the SAK as directed. In Kentucky, the Medical Protocol for Child Sexual Assault/Abuse Evaluation specifies pulling, not cutting, a minimum of 30 full-length hairs from various anatomical locations (Kentucky Association of Sexual Assault Programs, 2024).
• To collect head hair combings, the patient’s hair should be combed over a piece of paper after putting on new gloves. When appropriate, the patient can comb their own hair if preferred. The comb/hair/debris should be folded up with the paper, placed in the provided envelope, sealed, labeled, and placed in the SAK as directed.
• Clothing should be collected to recover possible foreign matter or DNA. Any existing damage to clothing should be documented and photographed. The collection protocol and process for different articles of clothing are as follows:
• Always collect the patient’s underwear when allowed, even if the patient has changed since the assault. This applies to underwear in contact with genitals, not bras. If the patient is not wearing underwear, collect the articles of clothing touching the patient’s anal and genital areas. Do not cut through any holes or rips in the underwear.
• Any clothing worn during the assault or immediately afterward may have foreign DNA, including bras, pants, and shirts. Coats, socks, and shoes do not always need to be collected. The articles chosen for collection should be based on the patient’s description of the assault and the examiner’s judgment. Only the patient’s underwear should be placed into the SAK.
• After putting on new gloves, the examiner should place a clean sheet on the floor, followed by the large changing paper in the SAK on top of the clean sheet. A gown can be held up to provide the patient privacy while removing clothing. The patient should be instructed to stand in the middle of the changing paper and place individual clothing items separately on the paper. The changing paper should be labeled, and each article of clothing should be inspected, documenting the item, color, and any damage. Damaged or stained clothing may be photographed. Each item of clothing should then be placed in a separate paper bag to prevent cross-contamination. Any wet clothing should be dried when possible. If unable to dry wet clothing, it should be arranged for release to law enforcement, notifying them that the clothing is wet.
• Any dried secretions and debris found on the patient should be collected. After changing gloves, the patient should be inspected from head to toe, and any suspected foreign material should be collected in the dried/secretions/debris envelope.
• Any debris should be placed in the paper provided in the SAK, sealed in an envelope, and labeled with the site.
• Any dried secretions should be flaked onto a paper bindle from the SAK. The site should be swabbed twice with two swabs moistened with sterile water.
• Touch DNA is collected to assess for foreign DNA on the patient. The collection of touch DNA should be based on the patient’s description of the assault and assessment findings. Any sites the patient states may have foreign DNA should be swabbed. If the patient lives with the suspect, touch DNA may not be as valuable forensically. Each area should be swabbed using two lightly moistened swabs. Each swab’s site and source should be documented using the patient’s own words.
• Fingernail swabs are collected to obtain foreign DNA. If the patient describes scratching the suspect, clippings may be more appropriate. New gloves should be worn, and one moistened swab should be run under the fingernails of one hand, using a separate swab for each hand. Using wooden sticks (or similar tools) to scrape under the nails is not recommended, as this may injure the patient. The two swabs should be sealed separately, labeled, and placed in SAK as directed.
• Any matted pubic hair can be clipped or swabbed with moistened swabs. If reference samples are taken, they should be collected by cutting or pulling (patients who are deceased ONLY) per policy or kit instructions. They should then be placed in the provided envelope, sealed, labeled, and placed in the SAK as directed. In Kentucky, the Medical Protocol for Child Sexual Assault/Abuse Evaluation specifies pulling, not cutting, a minimum of 30 full-length hairs from various anatomical locations (Kentucky Association of Sexual Assault Programs, 2024).
• Pubic hair combings (and comb) are collected to obtain trace evidence, including foreign hairs. This is most useful in the case of an unknown or acquaintance sexual assault. The process is similar to combing head hair described above. The paper is placed under the patient’s buttock, and the pubic hair is combed over the paper. Again, the patient can comb their own hair if preferred. The paper and comb should be sealed in the provided envelope, labeled, and placed in SAK as directed.
• Vulva swabs are collected to recover foreign DNA. New gloves should be worn to swab the vulva with two swabs simultaneously. The inner labia majora, labia minora, and the hymen should be included, avoiding the urinary meatus. The swabs can be premoistened with sterile water if instructions on the kit allow. Swabs should be sealed together, labeled, and placed in SAK as directed.
• Vaginal or cervical swabs are collected to recover foreign DNA. Vaginal and cervical swabs should only be collected from adolescents or adults unless the pediatric patient is sedated under the direction or supervision of a healthcare provider. Vaginal washings are not recommended, as they can dilute the sample obtained. New gloves should be worn to insert a vaginal speculum after photographs of any genital injuries have been obtained. Two dry swabs should be gently placed into the cervical os and held in place for 5 to 10 seconds; they should then be used to swab the surface of the cervix and the posterior fornix of the vagina. Swabs should be sealed together, labeled, and placed in SAK as directed.
• Penile swabs are collected to recover foreign DNA. A male patient may be allowed to swab their own penis at the discretion of the examiner. New gloves should be worn to swab the head of the penis with two premoistened swabs, avoiding the urethral meatus. The same two swabs should be used to swab under the foreskin and the shaft of the penis. Swabs should be sealed together, labeled, and placed in SAK as directed.
• Scrotal swabs are used to recover foreign DNA. Male patients may also swab their own scrotums when appropriate. New gloves should be worn to swab the scrotum using two premoistened swabs. Swabs should be sealed together, labeled, and placed in SAK as directed.
• Anal swabs are collected to recover foreign DNA. New gloves should be worn to swab around the external anus using two premoistened swabs. Swabs should be sealed together, labeled, and placed in SAK as directed.
• Retained objects in the vagina or rectum are collected to recover foreign DNA or evidence. This includes collecting tampons, menstrual cups, or retained objects. Any retained objects in prepubertal females should be collected under sedation by a healthcare provider or a supervised SANE. The object(s) should be allowed to air dry, if possible, and placed in a dried secretion/debris envelope labeled and sealed.

Evidence collection should not be done on a patient who is unconscious unless medically necessary and appropriate, and evidence collection should be stopped if the patient dies during the collection process. Samples should not be collected from patients who arrive at the facility deceased (COK, 2025a, 2025b). Once the evidence is collected, it should be documented and photographed. All evidence should be labeled and sealed in a corresponding envelope or paper bag. Each evidence sample should be labeled with the patient’s identifying information, including their legal name, date of birth, and medical record number; the date, time, and examiner’s signature or initials. All collection bags or envelopes should be put into the primary SAK container. The container should be closed, sealed, or taped, and the examiner should initial, date, and time across the seal to demonstrate a lack of tampering. The kit should also be labeled with the patient’s identifying information (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-b; Kleypas & Badiye, 2023; OVW, 2024). The summary of collecting evidence in adult and pediatric patients is outlined in Table 1, while Table 2 reviews samples that are not routinely recommended for collection.

Table 1

Summary of Evidence Collection Recommendations

                                                                                                (NIJ, 2017; OVW, 2016, 2024)

Table 2

Evidence Collection Not Recommended

                                                                                                (NIJ, 2017; OVW, 2016, 2024)

Documentation

Facilities should develop and approve forensic medical assessment documentation forms for their institution. The term alleged should be replaced with reported or stated when documenting the patient’s history. The term suspect is preferred when referencing the assailant/attacker. If an interpreter is used, this should be documented. The patient’s pertinent medical and surgical history (including obstetric history), the last menstrual period, and current medications should be documented. Once the forensic medical assessment is documented, one copy should be placed in the SAK, and a second copy should be made available to law enforcement. All originals should stay at the health care facility (Buchanan, 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2016, 2024).

When documenting the attack, the adolescent or adult patient should be asked to start from just before the assault to when they arrived at the facility. The examiner should document exactly what the patient says and place quotation marks at the beginning and end of their history, as direct quotes are best practice. The patient should be allowed to proceed at a pace that is comfortable for them. Extensive interviewing should be avoided for prepubertal children if the examiner is not forensically trained. If the patient is uncomfortable repeating their trauma aloud, they should be offered the option of writing their story down. Patients should be asked to clarify any unclear statements relevant to the medical forensic exam (Buchanan, 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2016, 2024).

            Injuries should be documented using body diagrams and photographs, or “no visible trauma noted” if no injuries can be observed. Only acute injuries should be recorded for adults unless the patient reports a pattern of abuse. All pertinent injuries should be documented in the case of a pediatric patient. The body diagram should include each injury’s measurements (i.e., in millimeters [mm] or centimeters [cm]), descriptions, and locations. The type of injury should be documented using the definitions provided above. Anal and genital injuries should be recorded using clock positions when the patient is supine. For example, an injury to the urethral meatus would be placed at 12 o’clock (Buchanan, 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2016, 2024).

Photographs

Informed consent must be obtained before taking photographs. Assent from a pediatric patient is also recommended, but informed consent must be obtained from an adult parent or guardian. Patients should be notified of how the photographs will be stored and used. Patients should be reassured that the photographs will only be used for medical forensic purposes and are protected in medical facilities. A court order can seal photographs after the legal proceedings. The institutional policy should outline the process for taking photographs, how the patient is identified in the photograph, and how the photographs are linked to the permanent medical record. Photographs may allow for additional expert opinions without requiring patients to undergo further assessments. Photographs are typically used during legal proceedings to show physical findings, and quality photos may be used to evaluate recurrent sexual abuse in children. Anal and genital pictures should not be released to law enforcement unless a subpoena or written patient consent is obtained (OVW, 2016, 2024). Tips for clear and accurate photographs include the following:

• use adequate lighting (avoid using a flash in the exam room because this can change the color of evidence, and include a color reference scale in photographs to support accurate color interpretation)
• maintain focus, keep the camera steady, and keep the perspective undistorted
• use a forensic scale or ruler for size reference
• take at least two photographs of each area, one with and one without scale
• photograph evidence in place before removing it or collecting it
• minimize background distractions
• take at least two shots at three orientations: a medium-range photograph of each injury, regional shots with injuries in context that show orientation on body parts, and close-up images of particular injuries with scale
• shield uninvolved breasts or genitals when possible (highly graphic photos are sometimes deemed inadmissible in court, leaving the case less credible)
• close-up images of hands and fingernails should include damaged or missing nails
• photograph any restraint marks or signs of bondage on wrists, ankles, or neck
• photograph any transfer evidence present, such as dirt, gravel, or plants
• photograph any bite marks (OVW, 2016, 2024)

STI Testing and Treatment

Informed consent is required for all testing performed on collected samples during the exam. Laboratory testing following a sexual assault may include the following:

• nucleic acid amplification tests (NAATs) for chlamydia and gonorrhea of any suspected penetration or contact sites
• wet prep or urine/vaginal NAAT for trichomoniasis
• wet prep or vaginal pH and potassium hydroxide for bacterial vaginosis (BV) and candidiasis
• serum samples for HIV, hepatitis B, and syphilis (Buchanan, 2026; CDC, 2021)

Trichomoniasis, BV, gonorrhea, and chlamydia are the most frequently diagnosed STIs among individuals who have experienced sexual violence. The presence of STIs does not necessarily indicate that the infection was transmitted during the attack, so the forensic exam presents an opportunity to identify preexisting infections. The CDC’s (2021) treatment guidelines for sexual assault include an empiric antimicrobial regimen for the prophylaxis of chlamydia, gonorrhea, and trichomoniasis for adult females; a regimen for the prophylaxis of chlamydia and gonorrhea is recommended for males. Medication and dosing information include the following:

• a single dose of ceftriaxone (Rocephin) 500 mg IM (1 g if over 150 kg) for gonorrhea
• doxycycline (Doryx) 100 mg PO twice daily for 7 days for chlamydia
• metronidazole (Flagyl) 500 mg PO twice daily for 7 days for trichomoniasis (female patients only; Buchanan, 2026; CDC, 2021)

No prophylactic antimicrobial treatment is recommended in pediatric patients due to the very low rates of STIs in children after assault or abuse. Testing can be considered individually in pediatric patients if risk factors are present for transmitting STIs. Postexposure hepatitis B vaccination should be offered if the patient does not have evidence of hepatitis B immunity and the suspect’s status is unknown. If the suspect is known to have hepatitis, unvaccinated patients should receive the hepatitis B vaccine and immunoglobulin (HBIG) therapy. The vaccine and HBIG should be administered at the time of examination if indicated, with follow-up doses of the vaccine at 1 to 2 and 4 to 6 months. Patients who were previously vaccinated but have not had postvaccination testing of immunity should receive a single vaccine booster dose. Human papillomavirus vaccination is recommended in patients aged 9 to 26 who are unvaccinated or incompletely vaccinated. Follow-up doses should be administered according to the patient’s age when vaccination is initiated. Recommendations for HIV postexposure prophylaxis (PEP) should be based on individual patient risk factors according to the CDC postexposure HIV risk assessment. If the patient is felt to be at risk of HIV exposure, PEP should be started immediately to enhance effectiveness (within 72 hr). A 28-day course of a three-drug regimen (bictegravir [BIC]/emtricitabine [FTC]/tenofovir alafenamide [TAF], brand name Biktarvy) can be started immediately by providing the patient with a 3- or 5-day starter pack and a prescription for the remainder of the treatment (Buchanan, 2026; CDC, 2021, 2025b).

Emergency contraception should be offered or considered for any patient of reproductive potential (i.e., who could become pregnant from the assault). It can be used within 5 days after sexual assault to decrease pregnancy risk. Emergency contraception works primarily by delaying or preventing ovulation, but it will not disrupt an established pregnancy. Informed consent should be obtained before pregnancy prophylaxis is administered. Emergency contraception is not the same as medication abortion; it is a method of birth control to be used occasionally in specific situations. Emergency contraception will not terminate an existing pregnancy. Most patients with contraindications to estrogen-containing birth control can use emergency contraception, as it does not contain estrogen. The standard prophylaxis is a single dose of levonorgestrel (Plan B One-Step) 1.5 mg PO, but a two-dose regimen of 0.75 mg PO is also effective. It is most effective when taken as soon as possible, preferably within 72 hr of exposure, but can be used up to 5 days after exposure (Buchanan, 2026; CDC, 2021; OVW, 2024).

Discharge Planning and Follow-Up Care

Discharge instructions should summarize the sexual assault exam, including the evidence collected, tests conducted, medications prescribed or administered, and other treatments provided. Patients should be made aware of any follow-up appointments that were scheduled or that need to be scheduled. Discharge paperwork should also contain contact information and business hours for local sexual assault advocacy programs. Instructions for follow-up evaluation should be clear. Patients should be educated about expected injury healing and other findings or changes that may occur after the assault. Follow-up may be scheduled 2 to 4 weeks after the assault for STI care, HIV testing, and administration of a subsequent hepatitis B vaccine dose. Screening should be performed for intimate partner violence and other forms of abuse, and the patient’s physical safety and emotional well-being should be addressed (Buchanan, 2026; London et al., 2026; NIJ, 2017; OVW, 2024). According to the NIJ (2017), it is not intrusive to ask questions such as:

• “Where are you going after discharge?”
• “Who will you be leaving and staying with?”
• “Will these people be able to provide you with adequate support?”
• “If you feel unsafe, what will you do to get help?”

Verify that the patient does not need an emergency shelter or alternative housing option. Some patients will be eligible for protection orders. The nurse must ensure that the patient feels safe upon discharge or should assist the patient in developing a plan to feel safe. Any planning must consider personal and specific concerns (e.g., a patient with a physical disability will necessitate placement in a shelter that can meet the needs of a patient who requires assistance with activities of daily living; Buchanan, 2026; London et al., 2026; OVW, 2024). The COK (2025a) also suggests the following information be provided to patients at discharge:

the Office of Claims and Appeals, as established in KRS Chapter 49

802 KAR 3:010 and 802 KAR 3:020, administrative regulations providing aid to individuals who have experienced violence

appropriate educational materials (as described in KRS 209A.130) if the patient may be experiencing intimate partner violence, as defined in KRS 209A.020

Evidence Preservation

Drying and Storage

Improperly drying and storing evidence may lead to mold or bacterial growth that destroys the evidence, so kit instructions should be read and followed carefully. Wet evidence should be air-dried in a clean environment to prevent contamination. Dry evidence should be placed in paper (not plastic) containers to prevent mold growth. Each sample should be stored according to the following recommendations from the NIJ (2017) to optimize the usefulness and validity of the samples collected. This temporary storage (less than 72 hr) will maintain the integrity of the evidence until it is picked up by law enforcement and brought to the forensic laboratory. Serum/blood samples should be refrigerated between 2°C and 8°C (36°F to 46°F), while urine samples should be frozen if not immediately processed. Wet items that cannot be dried should be frozen (preferred) or refrigerated. Dry biological stained items, hair, swabs with biological materials (dried), and buccal swabs can be temperature controlled between 15.5°C and 24°C (60°F to 75°F) and less than 60% humidity. Alternatively, swabs with biological materials can be refrigerated if wet. Law enforcement should submit evidence to the forensic laboratory as soon as possible, but within 7 days of collection. Long-term storage of kits is the responsibility of law enforcement and the forensic laboratory and mirrors most of the recommendations above for short-term storage (COK, 2025a, 2025b; NIJ, 2017; OVW, 2024).

Chain of Custody

Evidence should be collected with care to be admissible in legal proceedings. The chain of custody must be maintained and documented throughout the assessment and collection process. This includes documentation of the dates and times of each transfer and every individual handling the evidence. Evidence should be labeled with the patient’s name, date of birth, medical identification number, examiner’s initials, date, and time. Facility policy should dictate how the evidence inside the SAK is labeled (NIJ, 2017). With each transfer, the chain of custody documentation should include:

• receipt of evidence
• storage of evidence
• transfer of evidence
• date and time of transfer
• printed name and signature of each person transferring, receiving, or possessing evidence (NIJ, 2017)

Providing Testimony

It is recommended that jurisdictions notify examiners promptly if there will be a need for testimony in court. Pretrial preparation of examiners is recommended. Examiners should be prepared to testify as factual or expert witnesses if needed. Every examination should be documented with the expectation of a trial and the need to testify. Broad education on testifying in court is encouraged for examiners. The examiner should familiarize themself with typical courtroom proceedings, expectations, the types of testimony, and what can be said during each type. Testifying in court can be difficult, and cross-examination will likely occur. Examiners can perceive questions from defense counsel as hostile or intimidating and should be prepared to handle these situations effectively. Speaking to defense attorneys to help with pretrial preparations can educate examiners on defense perspectives and tactics. Examiners may want to prepare by reviewing new practices and related case law (OVW, 2024).

References

American College of Obstetricians & Gynecologists. (2025). Adult manifestations of childhood sexual abuse: Committee opinion number 498. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/08/adult-manifestations-of-childhood-sexual-abuse

American Nurses Association. (2023). How to become a forensic nurse. https://www.nursingworld.org/content-hub/resources/nursing-resources/how-to-become-a-forensic-nurse

American Nurses Association, & International Association of Forensic Nurses. (2017). Forensic nursing: Scope and standards of practice (2nd ed.). American Nurses Association.

American Nurses Credentialing Center. (2026). American Nurses Credentialing Center to welcome forensic nurses: SANE-A and SANE-P certifications will transfer from IAFN to ANCC. https://www.nursingworld.org/news/news-releases/2026-news-releases/american-nurses-credentialing-center-to-welcome-forensic-nurses

Bechtel, K., & Bennett, B. L. (2026). Evaluation of sexual abuse in children and adolescents. UpToDate. Retrieved September 29, 2026, from https://www.uptodate.com/contents/evaluation-of-sexual-abuse-in-children-and-adolescents

Brittingham, A., & Williams, A. (2024). Forensic nurses: An invaluable resource. Delaware Nurses Association. https://www.myamericannurse.com/forensic-nurses-an-invaluable-resource

Buchanan, J. A. (2026). Evaluation and management of adult and adolescent sexual assault victims in the emergency department. UpToDate. Retrieved September 28, 2026, from https://www.uptodate.com/contents/evaluation-and-management-of-adult-and-adolescent-sexual-assault-victims-in-the-emergency-department

Campana, D. (2026). ENA takes lead in forensic nursing’s future as stewards of IAFN legacy. Emergency Nurses Association. https://www.ena.org/news-publications/newsroom/ena-takes-lead-forensic-nursings-future-stewards-iafn-legacy

Centers for Disease Control and Prevention. (2021). Sexually transmitted infections treatment guidelines, 2021: Sexual assault and abuse and STIs. https://www.cdc.gov/std/treatment-guidelines/sexual-assault.htm

Centers for Disease Control and Prevention. (2024). About child sexual abuse. https://www.cdc.gov/child-abuse-neglect/about/about-child-sexual-abuse.html

Centers for Disease Control and Prevention. (2025a). About sexual violence. https://www.cdc.gov/sexual-violence/about/index.html

Centers for Disease Control and Prevention. (2025b). Antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—CDC recommendations, United States, 2025. Morbidity and Mortality Weekly Report, 74(1), 1–56. https://doi.org/10.15585/mmwr.rr7401a1

Center for Forensic Nursing Excellence International. (n.d.). Multidisciplinary glossary on sexual violence. Retrieved September 28, 2026, from https://www.cfnei.com/term-page/

Center of Excellence in Forensic Nursing. (n.d.-a). Commercial sexual activity. Texas A&M Health. Retrieved September 28, 2026, from https://tecp.forensic-nursing.tamu.edu/glossary/commercial-sexual-activity

Center of Excellence in Forensic Nursing. (n.d.-b). Medical forensic examination. Texas A&M Health. Retrieved September 29, 2026, from https://tecp.forensic-nursing.tamu.edu/protocol/protocol/adults-adolescents/medical-forensic-examination

Center of Excellence in Forensic Nursing. (n.d.-c). Petechiae. Texas A&M Health. Retrieved September 28, 2026, from https://tecp.forensic-nursing.tamu.edu/glossary/petechiae

Commonwealth of Kentucky. (2025a). 502 KAR 12:010. Sexual assault forensic-medical examination protocol. https://apps.legislature.ky.gov/law/kar/downloads/docs/16062/document.engrossed.pdf

Commonwealth of Kentucky. (2025b). Kentucky Revised Statute 216B.400. https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=56085

Duffy, J. R., & Hoskins, L. M. (2003). The quality-caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. https://doi.org/10.1097/00012272-200301000-00010

Federal Bureau of Investigation. (2012). UCR program changes definition of rape: Includes all victims and omits requirement of physical force. https://le.fbi.gov/cjis-division/cjis-link/ucr-program-changes-definition-of-rape

Feeney, H., Markey, J., Daye, C., Durall, A., Alonso, J., & Wilt, L. (2025). Victim-centered, trauma-informed practices. US Department of Justice. https://portal.cops.usdoj.gov/resourcecenter/content.ashx/cops-r1184-pub.pdf

Keith, J., & Skidmore, C. (2026). Sexual assault experienced as an adult. US Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/type/sexual_assault_adult.asp

Kentucky Association of Sexual Assault Programs. (2018). Toolkit for SAFE exam access. https://kbn.ky.gov/KBN%20Documents/sane-safe-toolkit.pdf

Kentucky Association of Sexual Assault Programs. (2024). Kentucky medical protocol for child sexual assault/abuse evaluation. Sexual Assault Response Team Advisory Committee. https://cackentucky.org/app/uploads/2025/07/KY-Medical-Protocol-CSA.-April-2024.-Approved.pdf

Kleypas, D., & Badiye, A. (2023). Evidence collection. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441852

London, S., Ford, C., Bawa, S., & Opland, C. (2026). Sexual assault trauma-informed approach: Evaluation, evidence collection, and documentation. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK614162

Mailhes, J., Yarrarapu, S. N. S., & Callahan, A. L. (2023). Sexual assault evidence collection and documentation. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557397

National Institute of Justice. (2017). National best practices for sexual assault kits: A multidisciplinary approach. US Department of Justice. https://nij.ojp.gov/topics/articles/national-best-practices-sexual-assault-kits-multidisciplinary-approach

Office of Justice Programs. (2016). Multidisciplinary sexual violence glossary. US Department of Justice. https://www.ojp.gov/library/publications/multidisciplinary-sexual-assault-glossary

Office on Violence Against Women. (2016). A national protocol for sexual abuse medical forensic examinations: Pediatric. US Department of Justice. https://www.justice.gov/ovw/file/846856/download

Office on Violence Against Women. (2024). A national protocol for sexual assault medical forensic examinations: Adults/adolescents (3rd ed.). US Department of Justice. https://www.justice.gov/ovw/media/1367191/dl?inline

Robinson, J. C. (2022). IAFN sexual assault nurse examiner (SANE-A®/SANE-P®) certification review (2nd ed.). Springer Publishing.

Sachs, C. J., Baker, M., & Vadakekut, E. S. (2026). Sexual assault history and physical. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448154

SAFEta.org. (n.d.). Use of terms. Retrieved September 28, 2026, from https://www.safeta.org/?page=ProtocolUseofTerms

Sexual Assault Kit Initiative. (n.d.). The neurobiology of trauma: Webinar series. Retrieved September 28, 2026, from https://www.sakitta.org/toolkit/index.cfm?fuseaction=tool&tool=48

Substance Abuse and Mental Health Services Administration. (2017). Tips for survivors of a disaster or other traumatic event: Coping with retraumatization (HHS Publication No. SMA-17-5047). https://store.samhsa.gov/sites/default/files/d7/priv/sma17-5047.pdf

Tabanejad, Z., Ebadi, A., & Banazadeh, M. (2025). A systematic literature review on the role of the forensic nursing. Journal of Education and Health Promotion, 14(1), 95. https://doi.org/10.4103/jehp.jehp_1869_23

US Department of Homeland Security. (2025). What is human trafficking? https://www.dhs.gov/blue-campaign/what-human-trafficking

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