Forensic Evidence Collection in Texas 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 considers 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 for individuals who experience sexual 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

The Texas government code chapter 420, also known as the Texas Sexual Assault Prevention and Crisis Services Act, puts forth procedures that an HCP must follow to collect evidence during a forensic examination. After a patient has sustained an assault, the personal nature of the exam requires specialized professional learning and expertise. To ensure adherence with Texas law, the Texas Board of Nursing requires nurses practicing in the emergency room and those who may perform a forensic examination to receive specific forensic evidence collection training (Center of Excellence in Forensic Nursing, n.d.-f).

The purpose of the Texas Evidence Collection Protocol (TECP) is to offer guidance for HCPs in Texas who provide forensic assessments on patients who experience sexual assault or those suspected of committing sexual offenses. The goal is to provide timely, comprehensive care while minimizing additional trauma to the patient. While the entire TECP can be accessed on the Texas Attorney General's website, the key points of the protocol are (Center of Excellence in Forensic Nursing, n.d.-f):

• Sexual assault is traumatic whether or not physical injuries are present.
• Emergent medical conditions should be treated before or concurrently with forensic issues (i.e., evidence collection).
• Nonfatal strangulation is a life-threatening medical event requiring specialized assessment and patient monitoring.
• Patients guide the assessment and have the right to decline the examination or evidence collection.

The protocol offers basic information for examiners and minimum requirements for forensic care. Key points mentioned in the forensic care of patients include (Center of Excellence in Forensic Nursing, n.d.-f):

• Examiners should use open-ended questions.
• All HCPs should be mindful of maintaining confidentiality.
• Access to a sexual assault advocate during the forensic medical assessment is mandated by Texas law. The advocate is a distinct and separate entity from the HCPs and law enforcement personnel.
• The reporting of abuse is mandatory if the patient is a child, a person with a disability, or an older adult. In Texas, these incidents must be reported regardless of the wishes of the patient, family, or friends.
• A forensic expert should see pediatric patients and suspected perpetrators (this includes SANEs and forensic nurse examiners).
• Contamination of potential evidence should be avoided while examining the patient and collecting evidence.
• Nurses should stay within their professional practice guidelines. This can be difficult when caring for indidivuals who experience sexual violence and trauma or suspected perpetrators.
• For military-affiliated survivors, reporting options must be given to them by someone knowledgeable about the US Department of Defense policies.
• Institutional policies should exist regarding obtaining photographs, identifying patients in photographs, and documenting the existence of such photographs in the patient's medical records. This includes the requirement for informed consent before photographing a patient.
• A sexual assault examination can occur without using an SAK. These kits should only be used when forensic evidence collection is necessary.

Adult survivors without a disability who are younger than 65 can choose whether to report the offense to law enforcement. When a patient chooses to report the incident, it should be reported to the law enforcement agency in the jurisdiction where it occurred. The patient should be given access to all support services, including health care treatment, evidence collection, and advocacy. If a patient chooses not to report the incident immediately, the evidence can be collected and processed up to 5 years later if the patient subsequently reports the crime. Nonreporting evidence can be submitted to the Texas DPS Crime Laboratory Service for storage. The evidence should be packaged in a box sealed with heavy tape. The examiner should initial the box so that part of the initials appears on the tape and part appears on the box. The box should be suitable for standard shipping. No liquid samples, such as blood or urine, should be included. These patients should be given access to the same support services. The patient may initially be responsible for payment for medical services, although the patient should be encouraged to seek reimbursement through the Crime Victims' Compensation Program. The facility or provider is responsible for the forensic services and may also seek reimbursement through the Crime Victims' Compensation Program (Center of Excellence in Forensic Nursing, n.d.-f).

A Victim-Centered and Trauma-Informed Approach

Sexual assault is a traumatic event that negatively affects overall health and well-being. A victim-centered approach consistently focuses on the individual 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 and Gynecologists, 2025; Keith & Skidmore, 2026; Robinson, 2022)

HCPs must inform patients about each step of the process before it occurs during the examination and offer choices whenever possible to reinforce the patient's self-determination and autonomy. Patients should be allowed ample time to answer questions, with a break 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 and openly to treat the patient properly and prevent further injury. However, these conversations should remain humane, respectful, and sensitive. It is best practice to start with less stressful questions about general health information and explain the rationale for every question. Once the interview focuses on the incident, the examiner should explain that reviewing exactly what occurred is necessary to provide the best available treatment. Questions should be open-ended, and the examiner should avoid questions that begin with "why." Patients may have more difficulty remembering details when seen immediately after the incident, especially if they have not slept. Because trauma can lead to serious conditions such as posttraumatic stress disorder and acute stress disorder, the patient's mental and physical needs should be addressed. A 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 violence. Patients who do not speak English and patients with vision or hearing impairments should be provided with interpreters or alternative communication tools to ensure effective and honest communication (Buchanan, 2026; London et al., 2026; OVW, 2024; Sachs et al., 2026).

The patient should be counseled about the potential benefits and consequences of reporting the incident to law enforcement when reporting is not mandatory for an adult patient. The patient decides whether to report the incident; the nurse should support that decision-making by answering questions and providing objective information. The victim advocate may also provide valuable support and insight into legal processes and procedures if the patient decides to report. Some jurisdictions have alternative reporting methods. As with other aspects of the process, reporting should be victim-centered. The medical examination can be completed regardless of whether the patient decides to report immediately. Evidence can be submitted later if the patient subsequently chooses to report (Buchanan, 2026; London et al., 2026; OVW, 2024; Sachs et al., 2026).

Before the Examination

Before beginning an examination, the examiner must obtain verbal and written consent. For an adolescent or pediatric patient, consent may need to be obtained from a legal guardian, depending on local jurisdictional requirements. The informed-consent discussion should explain the purpose of the samples, how the samples or kit may be used, and the patient's right to provide partial consent or withdraw consent at any time. When possible, the examiner should also explain relevant time frames, processing procedures, and how the patient may be notified of test results. The examination should occur in a quiet, safe, private environment and should not be interrupted by activity outside the examination area. 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)

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. In Texas, it is recommended that patients who experience sexual violence be triaged at a level 2. 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, n.d.-f; 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.-c; 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.-c; 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 experienced the violence. 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).

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).

SAKs

SAKs should meet or exceed minimum national guidelines. Standardizing kits within a jurisdiction and across a state or territory is recommended. In Texas, an Attorney General-approved SAK should be used if available (Center of Excellence in Forensic Nursing, n.d.-f). 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 5 days or longer post-assault. As technology advances, that period expands, and in some instances, can be up to 9 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.-c, n.d.-f; 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. Examiners should avoid cross-contaminating the evidence by changing gloves often and placing each sample into a separate container as instructed. The examiner should avoid speaking or coughing while handling swabs to avoid examiner contamination. 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 (deceased patients ONLY). As with previous samples, these should be sealed, labeled, and placed in the SAK as directed.
• 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 (deceased patients ONLY) per policy or kit instructions. They should then be placed in the provided envelope, sealed, labeled, and placed in the SAK as directed.
• 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 an HCP. 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 an HCP 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.

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. After removing the red evidence labels and orange biohazard labels from the kit, the examiner should change into new/clean gloves and seal the SAK with the red tape provided in the kit. The biohazard label should be affixed to the front of the SAK. All documentation on the front of the kit should be completed. The examiner must sign their name and write the date and time over the evidence tape so that the signature goes from the kit across the label back to the kit to demonstrate a lack of tampering during legal proceedings (Buchanan, 2026; Center of Excellence in Forensic Nursing, n.d.-c, n.d.-f; 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 institution-specific forensic medical assessment forms. When documenting the patient's history, the term alleged should be replaced with reported or stated. The term suspect is preferred when referring to the person identified as the assailant or attacker. The use of an interpreter should also be documented. Documentation should include the patient's pertinent medical and surgical history, including obstetric history; last menstrual period; and current medications. After the forensic medical assessment is documented, one copy should be placed in the SAK and a second copy made available to law enforcement. All original documents should remain at the health care facility (Buchanan, 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2016, 2024).

When documenting the incident, the examiner should ask an adolescent or adult patient to begin with the events immediately preceding it and continue through the patient's arrival at the facility. The examiner should record the patient's statement verbatim and enclose the account in quotation marks because direct quotation is best practice. The patient should be allowed to proceed at a comfortable pace. If the examiner lacks forensic training, extensive interviewing of a prepubertal child should be avoided. A patient who is uncomfortable recounting the trauma aloud should be offered the option of providing a written account. The examiner should ask the patient to clarify statements that are unclear and relevant to the medical forensic examination (Buchanan, 2026; Mailhes et al., 2023; NIJ, 2017; OVW, 2016, 2024).

Injuries should be documented using body diagrams and photographs. If no injuries are observed, the record should state, "No visible trauma noted." For adults, only acute injuries should be recorded unless the patient reports a pattern of abuse. For pediatric patients, all pertinent injuries should be documented. The body diagram should show the measurement of each injury in millimeters (mm) or centimeters (cm), along with its description and location. The injury type should be documented using the definitions provided above. Anal and genital injuries should be recorded using clock-face positions while the patient is supine. For example, an injury at the urethral meatus would be documented at the 12-o'clock position (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:

• 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 experience 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).

In Texas, the treatment guidelines for sexual assault mirror the CDC's. The Texas Attorney General encourages providers to consider postexposure hepatitis B vaccination, HIV prophylaxis, and HPV vaccination (for sexual assault patients over 9 years of age and through 26 years of age who have not previously been vaccinated). For patients under 45 kg, the treatment guidelines include:

• a single dose of ceftriaxone (Rocephin) 25 to 50 mg/kg IM (not to exceed 250 mg)
• erythromycin (Erythrocin) 50 mg/kg/day PO for 14 days, divided QID (Center of Excellence in Forensic Nursing, n.d.-f; CDC, 2021).

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).

Evidence Preservation

Drying and Storage

Improper drying or storage may promote mold or bacterial growth and destroy evidence; therefore, 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 NIJ (2017) recommendations to optimize its usefulness and validity. Temporary storage of less than 72 hr maintains evidence integrity until law enforcement retrieves the evidence and transports it to the forensic laboratory. Serum and blood samples should be refrigerated at 2°C to 8°C (36°F to 46°F), whereas urine samples should be frozen if they cannot be processed immediately. Wet items that cannot be dried should preferably be frozen or, when freezing is not possible, refrigerated. Dry items with biological stains, hair, dried swabs containing biological material, and buccal swabs may be stored in a temperature-controlled environment at 15.5°C to 24°C (60°F to 75°F) and less than 60% humidity. Swabs containing wet biological material may instead be refrigerated. Law enforcement should submit evidence to the forensic laboratory as soon as possible and within 7 days of collection. Long-term storage of kits is the responsibility of law enforcement and the forensic laboratory and generally follows the short-term storage recommendations described above (NIJ, 2017; OVW, 2024).

Chain of Custody

Evidence should be collected carefully so that it remains admissible in legal proceedings. The chain of custody must be maintained and documented throughout the assessment and evidence-collection process, including the date and time of each transfer and the identity of every person who handles the evidence. Evidence should be labeled with the patient's name, date of birth, medical identification number, the examiner's initials, and the collection date and time. Facility policy should specify how evidence within the SAK is labeled (NIJ, 2017). Documentation for each transfer should include the following:

• 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

Jurisdictions should notify examiners promptly when courtroom testimony may be required, and examiners should receive pretrial preparation. Examiners should be prepared to testify as either factual or expert witnesses. Every examination should be documented with the possibility of a trial and testimony in mind. Broad education about courtroom testimony is encouraged. The examiner should become familiar with typical courtroom proceedings, expectations, types of testimony, and the information permitted within each type of testimony. Courtroom testimony can be difficult, and cross-examination is likely. Because examiners may perceive questions from defense counsel as hostile or intimidating, they should be prepared to respond effectively. Pretrial discussions with defense attorneys may help examiners understand defense perspectives and tactics. Examiners may also prepare by reviewing current practices and relevant case law (OVW, 2024).

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