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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


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Part 3 - Professional Services

Chapter 29 - Sexual Assault

Title Section
Introduction 3-29.1
    Purpose 3-29.1A
    Scope 3-29.1B
    Background 3-29.1C
    Authorities 3-29.1D
    Policy 3-29.1E
    Definitions 3-29.1E
Responsibilities 3-29.2
    Director, IHS 3-29.2A
    Chief Medical Officer, IHS 3-29.2B
    Area Director 3-29.2C
    Area Chief Medical Officer 3-29.2D
    Chief Executive Officer 3-29.2E
    Facility Medical Director or Clinical Director 3-29.2F
    Facility Chief Nursing Officer 3-29.2G
    Behavioral Health and Social Services 3-29.2H
    Sexual Assault Examiner 3-29.2I
    Local Protocol Roles 3-29.2J
    Chain of Custody 3-29.2K
Informed Consent and Patient Authorization 3-29.3
    Informed Consent 3-29.3A
    Informed Consent - Patients under the Influence of Alcohol or Drugs 3-29.3B
    Patient Authorization 3-29.3C
Uniform Clinical Care Guidelines 3-29.4
    Patient Safety 3-29.4A
    Patient-Centered Care 3-29.4B
    Clinical Forensic Examination Services 3-29.4C
    Timing Considerations for Collecting Evidence 3-29.4D
    Access by Referral 3-29.4E
    Transportation 3-29.4F
    Anonymous Evidence Collection Kits 3-29.4G
Non-Reporting 3-29.5
Medical Records 3-29.6
    Use of Medical Records 3-29.6A
    Release Requirement 3-29.6B
    Use of Medical Information 3-29.6C
Suspect Examinations 3-29.7
    Suspect Examination 3-29.7A
    Who May Perform the Suspect Examination 3-29.7B
    Exceptions 3-29.7C
    Patient Refuses Consent 3-29.7D
Sexual Assault Examiner Training, Competencies, Credentialing, and Privileging 3-29.8
    Adult/Adolescent SAE Training 3-29.8A
    Suspect Examinations 3-29.8B
    Credentialing and Privileging 3-29.8C
    Competencies 3-29.8D
    Minimum Number of Yearly Examinations 3-29.8E
    Continuous Quality Improvement 3-29.8F
Responding to a Subpoena and Testifying in Court 3-29.9

3-29.1  INTRODUCTION

  1. Purpose.  The purpose of this chapter is to ensure that sexual assault services are patient-centered, culturally sensitive, and part of a coordinated community response.
  2. Scope.  This chapter establishes uniform clinical care guidelines for patients 18 and older who present for sexual assault services at Indian Health Service (IHS) hospitals, health centers, and health stations (hereafter referred to as facilities). All facilities providing sexual assault services will ensure that those services are provided consistently and result in complete sexual assault medical forensic examinations and appropriate documentation.
  3. NOTE:  For children aged 17 and under who present with concerns of sexual abuse, refer to the IHS child abuse policies and procedures for treatment (See Part 3, Chapter 13, Section 8, "Sexual Abuse," Indian Health Manual (IHM)).

  4. Background.  According to the Centers for Disease Control and Prevention (CDC), American Indian/Alaska Native (AI/AN) women experience the highest percentage of sexual assault in the U.S. Sexual assault can result in physical trauma and significant mental anguish and suffering for victims.  Victims, particularly males, may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons.  A timely, high-quality medical forensic examination can potentially validate and address sexual assault patients' concerns, minimize the trauma they may experience, and promote their healing.  At the same time, it can increase the likelihood that evidence collected will aid in criminal case investigation, resulting in perpetrators being held accountable and preventing further sexual violence (Department of Justice's National Protocol on Sexual Assault Medical Forensic Examinations, 2013).

    Additionally, sexual assault can co-occur with intimate partner violence. The response to sexual assault occurring within an intimate partner relationship requires understanding of the overlap of both dynamics; the complex needs and safety of victims; the potential dangerousness of offenders; and resources available for victims. The response also requires adherence to jurisdictional policies on intimate partner violence.

    It is important to be aware that victims may also be intersex or transgender. These victims may have unique issues, including: gendered histories that encompass more than one gender; pervasive experience with discrimination, violence, prejudice, and invasive curiosity; identity documents or other paperwork that do not match their current identity; or bodily configurations that do not align with expectations of some members of the public or medical personnel. Health care providers should be aware of these differences to ensure the appropriate response to transgender victims.
  5. Authorities.

    1. Indian Law Enforcement Reform Act, 25 United States Code (U.S.C.) §§ 2801 et seq., as amended
    2. Indian Health Care Improvement Act, 25 U.S.C., §§ 1601 et seq., as amended
    3. Indian Child Protection and Family Violence Prevention Act, 25 U.S.C. §§ 3201 et seq.
    4. Snyder Act, 25 U.S.C. §13
  6. Policy.  It is the policy of the IHS that:

    1. All IHS-operated facilities shall provide patients 18 and older who present with a report of sexual assault with access to a sexual assault medical forensic examination either onsite and/or by referral.
    2. If patients are transferred offsite for services, all transfers must comply with the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd
    3. Every facility shall develop local policy and procedures for responding to sexual assault (See 3-29.4 IHM).
  7. Definitions.

    1. Anonymous Sexual Assault Evidence Collection Kit.  An Anonymous Sexual Assault Evidence Collection Kit (anonymous evidence kit - See also 3-29.1E(14)) is a kit that is used in the event that the sexual assault victim either declines to report to law enforcement or is undecided about reporting at the time of exam and chooses to remain anonymous.  A unique identifier must be created for each kit.  The Health Insurance Portability and Accountability Act (HIPAA) of 1996 Privacy Rule, at 45 Code of Federal Regulations (CFR) 164.514(b)(2), prohibits the use of any other existing identifier, including the medical record number or the patient account number.
    2. Behavioral Health Providers. Behavioral health providers include psychiatric mental health nurse practitioners, licensed clinical social workers; licensed marriage and family counselors; licensed professional counselors; licensed addictions counselors; clinical psychologists; and psychiatrists (medical doctor and doctor of osteopathy).
    3. Chain of Custody.  Chain of custody is the preservation of physical evidence from the time of its collection until the time that it is presented as evidence at trial.  Chain of custody requires that the evidence be maintained either by packaging and/or custody in a manner that ensures that the evidence has been neither tampered with nor contaminated between collection and admission.  The chain of custody also requires that, from the moment the evidence is collected, every transfer of evidence from person to person be documented.  It must be demonstrable that no unauthorized individual had access to the evidence.  The transfer of evidence must be kept to a minimum.  Contact the regional Office of the General Counsel (OGC) for guidance on chain of custody procedures.
    4. Coordinated Community Response.  This term refers to the community response to sexual assault that is coordinated among involved agencies, organizations, and staff.  While the IHS provides sexual assault medical forensic examination services and interventions according to IHS-specific policies, the IHS also works with Tribal, State, and Federal agencies (such as, law enforcement, prosecution, etc.) and various professionals to ensure a coordinated response.  The desired result is a collective response to victims that is appropriate, streamlined, and as comprehensive as possible.  This coordinated effort may be called a sexual assault response team (SART), but may also have other names.
    5. Confidentiality.  Medical records of IHS program patients, including records contained in the IHS Privacy Act System of Records Notice 09-17-0001 Medical, Health, and Billing Records, are subject to the following laws:  the Privacy Act, 5 U.S.C. § 552a; the Freedom of Information Act, 5 U.S.C. § 552; the Drug Abuse Prevention, Treatment, and Rehabilitation Act, 21 U.S.C. § 1101; the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act, 42 U.S.C. § 4541; HIPAA, Confidentiality of Medical Quality Assurance Records, 25 U.S.C. § 1675; the Patient Safety and Quality Improvement Act of 2005; 42 U.S.C. §§ 299b-21 to -26; and Federal regulations promulgated to implement those acts, including the HIPAA Privacy Rule (45 CFR Parts 160 and 164).

      Note:  Unless Federal laws or regulations provide otherwise, State laws requiring disclosure of protected health information (PHI) do not apply to the IHS.

      When medical records and other PHI are needed for use or disclosure not authorized by Federal law, the written authorization of the patient and/or a valid court order or subpoena is required.  Consultation with the regional OGC is encouraged to ensure that all uses and disclosures of medical information under this policy are compliant with the law.
    6. Consent for Sexual Contact.  An individual's capacity to consent to sexual contact is defined by law, and consent varies by factors, such as mental status and level of consciousness.  Individuals with certain disabilities may or may not be able to consent for sexual contact.  Facilities must consult their regional OGC for further guidance.
    7. Drug or Alcohol Facilitated Sexual Assault.  A drug or alcohol facilitated sexual assault occurs when drugs or alcohol are intentionally given to a victim by a perpetrator or are voluntarily consumed by the victim, rendering the victim unable to consent to sexual activity.  The drugs or alcohol minimize the resistance and memory of the victim of a sexual assault.
    8. Informed Consent.  Informed consent is the process by which a fully informed patient can participate in choices about his or her health care.  The patient must be given all relevant information prior to the medical procedure.  This includes information about the impact of declining a procedure, which may negatively affect the quality of care and the thoroughness or usefulness of evidence collection.  Informed consent includes a discussion of the following elements:

    9. The nature of the decision or procedure.
    10. Reasonable alternatives to the proposed intervention.
    11. The relevant risks, benefits, and uncertainties related to each alternative.
    12. Assessment of patient understanding, including interpretation services when needed.
    13. The acceptance of the intervention by the patient.
  8. Intimate Partner Violence.  Intimate partner violence is physical, sexual, or psychological harm by a current or former partner or spouse.  This type of violence can occur among heterosexual or same sex couples and does not require sexual intimacy.
  9. Jurisdiction.  The term jurisdiction is defined as:  the power, right, or authority to interpret and apply the law; the authority of a sovereign power to govern or legislate; the power or right to exercise authority; or the limits or territory within which authority may be exercised.
  10. Patient Authorization.  Patient authorization is the right of patients to request restriction(s) on how their protected health information (PHI) can be used or disclosed to carry out treatment, payment, and health care operations, hospital directory; or disclosed to relatives, family members, close friends, health care givers, and any other person involved in the patient's care or payment who is identified by the patient. Except to the extent otherwise required (or permitted) by federal law, the IHS must obtain prior written authorization from the patient before disclosing health information, including the release of sexual assault medical records, photographic images, and the release of forensic evidence.

  11. Patient-Centered Care.  Patient-centered care as used in this policy recognizes that sexual assault victims are central in the decision making processes of the sexual assault medical forensic examination, and they deserve timely, compassionate, respectful, and appropriate care.  Victims have the right to be fully informed in order to make their own decisions about participation in all components of the exam process.  Responders need to explain possible options, the consequences of choosing one option over another, available resources, as well as supporting victims in their choices.  Responders outside of the health care community may refer to this as victim-centered care.
  12. Priority Treatment.  Priority treatment refers to immediate and more private care for victims of sexual assault.  Priority treatment is implemented by bringing the patient into a private exam room or private waiting area away from main waiting areas and other patients.  The patient's privacy and safety must be ensured.  Visitors shall be screened in coordination with facility security and not permitted access to the patient without his or her consent.
  13. Sexual Assault.  Sexual assault refers to a range of behaviors, including but not limited to a completed nonconsensual sex act, an attempted nonconsensual sex act, and/or abusive sexual contact.  Sexual assault includes any sexual act or behavior that occurs when the victim does not or cannot consent.  Lack of consent may be inferred when a perpetrator uses force, threat of force, or coercion; or when the victim is asleep, incapacitated, unconscious, or physically or legally incapable of consent.  Victims of sexual assault may or may not know the perpetrator(s) and/or may be involved in a marital or dating relationship with the perpetrator.
  14. Sexual Assault Evidence Collection Kit.  The sexual assault evidence collection kit includes materials used to collect forensic evidence during the sexual assault medical forensic examination and after the examination.
  15. Sexual Assault Examiner.  A sexual assault examiner (SAE) is a registered nurse, advanced practice nurse, physician, or physician assistant who has been specially trained to provide care to sexual assault patients.  The SAE is a health care provider who conducts sexual assault medical forensic examinations.  They are also referred to as sexual assault nurse examiners (SANEs) and sexual assault forensic examiners (SAFEs).
  16. Sexual Assault Forensic Evidence.  Sexual assault forensic evidence collected as a part of the sexual assault medical forensic examination may include (but is not limited to): the patient's clothing and underwear; foreign material dislodged from clothing; foreign material on the patient's body, including blood, dried secretions, fibers, vegetation, soil, or debris; fingernail scrapings and/or cuttings; material dislodged from the mouth; swabs of suspected semen and saliva; vaginal/cervical swabs and smears; penile swabs and smears; anal/perianal swabs and smears; oral swabs and smears; and body swabs.,/li>

  17. Sexual Assault Medical Forensic Examination.  The sexual assault medical forensic exam is an examination of a sexual assault patient by a health care provider, ideally one who has specialized education and clinical experience in the collection of forensic evidence and treatment of these patients.  The examination includes:  Gathering information from the patient for the medical forensic history; an examination; coordinating treatment of injuries, documentation of biological and physical findings, and collection of evidence from the patient; information, treatment, and referrals for sexually transmitted infections, pregnancy, suicidal ideation, alcohol and substance abuse, and other non-acute medical concerns; and follow-up as needed to provide additional healing, treatment, or collection of evidence.
  18. Sexual Assault Response Team.  A SART is a multidisciplinary team that provides a coordinated response to victims of sexual assault (see coordinated community response).

    NOTE:  The IHS does not mandate and is not solely responsible for the development or implementation of a SART.  However, the IHS shall be an active participant in the local Tribal SART or other coordinated community response to sexual assault.
  19. Sexual Assault Victim Advocate.  A sexual assault victim advocate may offer victims and their significant others a range of services during, and following, the exam process.  These services may include support, crisis intervention, information and referrals, interpretation or translation, and advocacy to ensure those victims' interests are represented, their wishes are respected, and their rights are upheld.

    A number of agencies may offer some or all of the services described above, including community-based sexual assault victim advocacy programs, law enforcement agencies, criminal justice system victim-witness offices, Tribal social services, adult protective services, and others.  It is important to know that information victims share with government-based service providers usually becomes part of the criminal justice record, while community-based advocates typically can provide some level of confidential communication for victims.

    NOTE:  The IHS does not employ sexual assault victim advocates.

3-29.2  RESPONSIBILITIES

  1. Director, IHS.  The Director, IHS is administratively responsible for ensuring that all Area Directors, Area Chief Medical Officers, and Service Unit Chief Executive Officers implement and monitor compliance with this policy.
  2. Chief Medical Officer.  The IHS Chief Medical Officer (CMO) is responsible for developing, publicizing, and assigning Headquarters staff to assist in the implementation and monitoring of compliance with this policy.
  3. Area Director.  The Area Director is responsible for ensuring that administrative support and resources are made available in his or her Area to implement and monitor compliance with this policy.
  4. Area Chief Medical Officer.  The Area CMO is responsible for monitoring IHS facilities for sexual assault policy compliance.
  5. Chief Executive Officer.  The Service Unit Chief Executive Officer (CEO) is responsible for:

    1. Ensuring the facility drafts local protocols and procedures outlining the requirements set forth in this policy.
    2. Approving the facility's sexual assault response policy and ensuring the policy is:  fully implemented; reviewed and updated annually; and submitted annually to the IHS Area CMO and to the IHS SANE-SART coordinators for monitoring purposes.
    3. Ensuring the facility has an intimate partner violence response policy that:

      1. Works in tandem with the sexual assault response policy.
      2. Is fully implemented, reviewed, and updated annually.
      3. Is submitted annually to the IHS CMO and to the IHS SANE-SART Coordinators for monitoring purposes.
    4. Ensuring the facility has the necessary equipment and supplies for conducting a sexual assault examination, such as, digital cameras, tape measures, evidence collection kit supplies, extra clothing, traditional healing items, subsistence, etc.
    5. Ensuring the facility has the required, secure (locked) storage capacity for biological and forensic evidence.
    6. Identifying a SAE coordinator or liaison within each facility who will participate in the local coordinated community response to sexual assault, by attending regular meetings (where scheduled), and obtaining feedback from stakeholders on the facility's sexual assault response and forensic evidence collection policies and protocols.
    7. Ensuring the SAE liaison identifies community resources that are available for victims of sexual assault, including culturally appropriate resources, such as traditional healers and language interpreters, and that these resources are available to patients when needed.
    8. Ensuring local policies address payment of the examination by the appropriate funding source so that patients are not required to pay out-of-pocket expenses for sexual assault medical forensic examinations.
  6. Facility Medical Director or Clinical Director.  The facility's medical director or clinical director is responsible for:

    1. Participating in establishing local sexual assault policies and procedures.
    2. Ensuring that medical staff bylaws, local policies, and procedures allow registered nurses with specialized Sexual Assault Examiner training to be designated as a qualified health care provider in order to provide medical screening examinations in cases of sexual assault.
    3. Establishing collaborative practice agreements for non-prescribing examiners for:  Standing medication and laboratory orders; signing orders and charts; and supervision for registered nurses practicing as SAEs.
    4. Ensuring that the medical staff receive required annual sexual violence training.
    5. Establishing local credentialing and privileging processes for conducting sexual assault medical forensic examinations.
  7. Facility Chief Nursing Officer.  The facility chief nursing officer is responsible for:

    1. Developing the facility's sexual assault policy and procedures in accordance with the requirements set forth in this policy.
    2. Ensuring SAE coverage is available during operating hours and/or through on-call coverage if the facility provides onsite sexual assault medical forensic examinations.
    3. Ensuring referral procedures are in place after hours or when an SAE is unavailable.
    4. Developing a process for continuous quality improvement review of all sexual assault medical forensic examinations in coordination with the facility medical director or clinical director.
    5. Assisting in the development of standing orders for registered nurses practicing as SAEs.
    6. Assisting in the development of local competencies for nursing staff for SAE practice.
    7. Ensuring approval for registered nurses to attend SAE and clinical skills training.
    8. Ensuring staff in the nursing department receive required annual sexual violence training.
    9. Ensuring training records are kept for compliance in each facility and made available upon request from the Area CMO or IHS SANE-SART coordinators.
  8. Behavioral Health Provider.  The behavioral health provider is responsible for:

    1. Evaluating the behavioral health needs of sexual assault victims and providing counseling, follow up care, or a referral for specialty care as needed.
    2. Participating in the development of local facility policies and protocols and serving as a member of the community SART, where SARTs exist, or participating in other coordinated community responses.
  9. Sexual Assault Examiner.  The SAE will gather the medical history from the patient for the purposes of medical diagnosis and treatment and to guide evidence collection.  If the victim chooses to involve law enforcement, the SAE shall work in conjunction with law enforcement to coordinate and streamline the medical history to reduce repeated questioning.  The medical history component shall be gathered by the SAE, not law enforcement.  The SAE is responsible for:

    1. Conducting the sexual assault medical forensic examination and referring patients for additional follow up care.
    2. Treating all victims of sexual assault with dignity and respect and providing patient-centered care.
    3. Ensuring patient confidentiality.
    4. Coordinating with the sexual assault victim advocate, if available, to ensure that patients are offered crisis intervention, support, and advocacy before, during, and after the examination process, and offering support person(s) of the patient's choosing, or offering other victim services, including spiritual or faith-based consultation.
    5. Coordinating with law enforcement as needed.
    6. Obtaining informed consent.  (For more information, please refer to 3-29.3 IHM; see also 3-3.13 and 3-3.14 IHM, and the Office of Clinical and Preventive Services, Chapter 6, "Informed Consent," Risk Management & Medical Liability Manual, and the Service Unit's informed consent policies.)
    7. Providing comfort and pain management measures per facility protocol.
    8. Providing information and prophylactic treatment for sexually transmitted infections, including HIV, in compliance with local policies and procedures for non-prescribing examiners.
    9. Screening for pregnancy and providing emergency contraception for pregnancy prevention if the patient chooses, in compliance with local policies and procedures for non-prescribing examiners.
    10. Maintaining the chain of custody according to local jurisdictional requirements.
    11. Releasing the sexual assault evidence collection kit, including clothing and other forensic evidence to law enforcement, with patient authorization or as required by law.
    12. Providing information and follow up referrals for medical, behavioral health, and forensic purposes.
    13. Notifying his or her supervisor and/or the facility CEO that he or she has received a subpoena to testify.
  10. Local Protocol Roles.  The following roles shall be addressed in local protocols.

    1. Reception/Intake/Registration.  All patients presenting with a report of sexual assault shall receive priority treatment.  The triage nurse shall be notified immediately.
    2. Triage Nurse.  All victims of sexual assault shall be triaged as priority patients.
  11. Chain of Custody.  All staff involved in handling, documenting, transferring, and storing evidence must be trained in how to properly preserve evidence and maintain the chain of custody.

    1. Handling Evidence.  he SAE and all other staff who handle sexual assault forensic evidence (including the forensic evidence collection kit, the victim's clothing, photos, etc.) are responsible for securing the chain of custody by documenting the collection, storage, transfer, and disposition of the forensic evidence.
    2. Evidence Integrity.  The SAE shall protect the integrity of the evidence and guard the chain of custody by properly drying, packaging, labeling, and sealing all evidence collected, including clothing (particularly the clothing worn closest to the genitals).
3-29.3  INFORMED CONSENT AND PATIENT AUTHORIZATION

  1. Informed Consent.  An informed consent procedure shall be developed for each facility.

    1. Health care providers and other responders are required to seek the informed consent of patients as appropriate throughout the exam process.  There are two consent processes: one for medical evaluation and treatment and one for the evidence collection.
    2. Informed consent for the sexual assault medical forensic examination and evidence collection is typically required for:

      1. Photograph images, including colposcopic images.
      2. The examination itself and evidence collection.
      3. Toxicology screening, if indicated, in cases of suspected drug or alcohol-facilitated sexual assault.
  2. Informed Consent - Patients under the Influence of Drugs or Alcohol.  The patient's decision-making capacity to provide informed consent should be based on clinical judgment and in accordance with IHS policy.  For more information, please refer to Sections 3-3.13 to 3-3.14 IHM and Chapter 6, IHS Risk Management Manual.  In the development of local policies and procedures, consult the regional OGC, as well as, Service Unit and Area risk managers regarding applicable consent laws.

  3. Patient Authorization.  Written patient authorization may be required to release photographic images, medical records, and evidence to law enforcement and to contact the patient after the sexual assault medical forensic examination for case management, follow up testing, referral information, and/or destroying evidence kits collected during the sexual assault medical forensic examination.  Prior to disclosing health information, including the release of sexual assault medical records, photographic images, and the release of forensic evidence, Form IHS 810 - Authorization for Use or Disclosure of Health Information must be completed and signed.  Consultation with the regional OGC is encouraged to ensure that all uses and disclosures of medical information under this policy are compliant with the law (see Manual Exhibit 2-7-D).

3-29.4  UNIFORM CLINICAL CARE GUIDELINES

  1. Patient Safety.  Patient safety must be ensured by notifying security, limiting visitor's access to the patient without the patient's consent, and requesting law enforcement presence, if needed.  Discharge planning for patient safety should be addressed in local policies and coordinated with appropriate local victim services personnel, where available.
  2. Patient-Centered Care.  Each sexual assault patient shall be:

    1. Triaged as priority treatment patients.
    2. Provided a full explanation of the examination process, including the use of language interpreters when needed.
    3. Provided with immediate access to a private examination room and/or private waiting area.
    4. Offered prophylactic medications against sexually transmitted infections and immunizations for tetanus and hepatitis B, when appropriate.
    5. Offered HIV post-exposure prophylaxis to the patient if the sexual assault was within the timeframe recommended for post-exposure prophylaxis; provided access to a 3-day supply of medication at the time of examination with provisions for the remaining course of medication, without cost to the patient; and provided coordination for referral and follow-up medical care.
    6. Offered emergency contraception to all females of reproductive ability and, if accepted, provided emergency contraception medication.
    7. Offered the services of a non-IHS employed sexual assault victim advocate, where available, and persons of her or his choosing; informed of the potential for individuals who are providing personal support (other than advocates with privilege) and government system-based victim service professionals to be subpoenaed if they are present during the medical forensic history; and given the right to accept or decline victim services at any time.
    8. Accommodated when the request for a health care provider of a specific gender to conduct the sexual assault examination is made.
    9. Offered referral and follow-up medical, behavioral health, community, or other available victim services and resources, as needed.
    10. Informed in order to make their own decisions about participation in all components of the sexual assault medical forensic examination process, including receiving explanations of all possible options, the consequences of choosing one option over another, and supported in their choices.
  3. Clinical Forensic Examination Services.  Adult clinical forensic examination services are primarily the Chief Nursing Officer's official area of responsibility; however, physicians and physician assistants may conduct sexual assault medical forensic examinations as part of their credentialing and privileging process.  All health care providers shall meet minimum training standards set forth in Section 3-29.5.
  4. Timing Considerations for Collecting Evidence.  Deoxyribonucleic acid (DNA) technology is extending the time period when evidence can be collected; however, jurisdictional policies still vary.  All SAEs shall be familiar with local jurisdictional crime laboratory recommendations regarding time frames for evidence collection.  All patients should have a medical history gathered, medical examination, medical documentation, and with consent, evidence gathered for the sexual assault evidence collection kit.
  5. Access by Referral.  All IHS-operated facilities that provide access to sexual assault medical forensic examinations by referral shall:

    1. Have local policies, protocols, and procedures that outline the referral process, including the name and location of the offsite provider.
    2. Refer to centers that provide a higher quality of care, employ trained SAEs, and have access to appropriate forensic equipment.
  6. Transportation.  All IHS-operated facilities shall have local policies, protocols, and procedures in place outlining transportation services to include:  Transportation when the patient requires or requests facility-funded transportation and transportation services when provided by a partner agency, organization, or service.  Transportation shall require coordination for facility-funded transport of the patient to and from the referral provider in compliance with EMTALA, if applicable.

    1. Transportation to the referral provider shall be no more than 2 hours of travel time from the IHS facility.
    2. Transportation may be coordinated with victim advocacy, social services, or another service agency providing transportation for victims of sexual assault.  However, if no other service is available, or at the patient's request, the IHS shall provide facility-funded transportation to and from the referral facility.
  7. Anonymous Evidence Collection Kits.  If the patient is reluctant to report the assault to law enforcement, the healthcare provider will inform the patient of the option of conducting a sexual assault medical forensic examination, collecting the forensic evidence, and storing the evidence as an anonymous sexual assault evidence kit.  Local policies and protocols must address how the kit will be destroyed, removal of any identifiable patient information prior to disposition, and obtaining patient authorization to contact her/him after the assault.

    1. Anonymous evidence collection kits shall be labeled with a unique alphanumeric identifier.  Medical record and patient account numbers may not be used as a unique alphanumeric identifier if the kits are turned over to law enforcement.

    2. Ideally, local law enforcement will have policies in place that address the storage of anonymous evidence kits.  If local law enforcement policies for anonymous evidence kits do not exist, the kit must be stored at the IHS facilities for no longer than 6 months.  The patient must be informed at the time of the examination that kits will be destroyed 6 months later.  If patients are to be contacted prior to the disposition of evidence, previous patient authorization must be obtained.
3-29.5  NON-REPORTING

Sexual assault victims shall not be required to report the sexual assault to law enforcement in order to have access to a sexual assault medical forensic examination or to have evidence collected.

NOTE: A provider may be required to report a sexual assault to maintain his or her state licensure.  This obligation may still apply where patients choose not to cooperate with the criminal justice system. However, the medical provider can meet his/her reporting obligation without the victim needing to cooperate.

3-29.6  MEDICAL RECORDS

  1. Release of Medical Records.  Each facility shall develop, approve, and implement a policy that addresses the:

    1. Maintenance, secure storage of medical records.
    2. Release of photographic images.
    3. Release of the sexual assault medical forensic examination record.
  2. Release Requirement.  The policy will include the requirement that all IHS staff (including medical records staff) must comply with the release of medical records only with proper patient authorization and/or subpoena or valid court order, or pursuant to other applicable law.
  3. Use of Medical Information.  The sexual assault victim's medical information may be disclosed for law enforcement purposes to the extent permitted or otherwise required by Federal law.  To the extent permitted by Federal law, the sexual assault victim's medical information may also be shared in private, interagency, interdisciplinary meetings whenever those meetings are not open to the general public and participants in the meeting are required to keep conference proceedings confidential.

3-29.7  SUSPECT EXAMINATIONS

  1. Suspect Examination.  All IHS personnel should promptly respond to law enforcement requests to conduct a suspect examination.  Because evidence of a sexual offense can dissipate rapidly, law enforcement officials are often working under significant time constraints imposed by law, and the IHS facility may be the only reasonable resource available to conduct such exams.  This cooperation, however, may be appropriately deferred when clinical judgment indicates a priority exists to provide health care to a medically unstable, seriously ill, or injured patient.  The evidence collected shall be directly and immediately provided to law enforcement officers for chain of custody accounting, including laboratory processing.
  2. Who may Perform the Suspect Examination.  Suspect examinations may be performed by physicians, physician assistants, advanced practice nurses, registered nurses, or SAEs; however, the same staff shall not perform the exam on both the suspect and the victim.
  3. Exceptions.  The suspect examination will not be conducted if one or more of the following exceptions apply:

    1. Such an exam is not authorized by controlling applicable law.
    2. The patient presents a danger to IHS personnel.
    3. There is a medical contraindication to conducting the exam.
    4. The patient refuses consent.
  4. Patient Refuses Consent.  If the patient refuses, the IHS staff member should not conduct the exam and document the patient's refusal in the medical record.

3-29.8  SEXUAL ASSAULT EXAMINER TRAINING, COMPETENCIES, CREDENTIALING, AND PRIVILEGING

NOTE:  SANE certification is not a requirement for practice at IHS-operated facilities.

  1. Adult/Adolescent SAE Training.  Forty hours of SAE training is required for all registered nurses, advanced practice nurses, physicians, and physician assistants new to the specialized area of caring for adult and adolescent sexual assault patients.  All SAE training must yield 40 contact hours, academic credits, or national equivalents.  All SAE training must conform to the Adult and Adolescent SANE educational requirements of the International Association of Forensic Nurses and the U.S. Department of Justice's National Sexual Assault Forensic Medical Examination Training Standards.

    1. Clinical Skills Competency. Direct patient care clinical preceptorship is required for all registered nurses, advanced practice nurses, physicians, or physician assistants who are new to the field of clinical forensic services or need a refresher course for clinical skills.  Clinical preceptorship shall be completed with the guidance of a forensically experienced physician, a physician assistant, advanced practice nurse, or registered nurse employed through an IHS or Tribal health care facility, a high-volume SAE program, or a simulation clinical skills laboratory setting.  Clinical preceptorship content must meet the educational requirements of the International Association of Forensic Nurses and the Department of Justice's National Sexual Assault Forensic Medical Examination Training Standards.

      NOTE:  Competency is determined by the professional assessing the required clinical skills.
    2. Continuing Education. The continuing education requirement for SAEs is 2 hours of annual relevant sexual assault training.  The training may be completed by continuing education, webinars, peer review, clinical skills training, or conference attendance.
  2. Suspect Examinations.  Health care professionals should also receive training on evidence collection for suspect examinations.
  3. Credentialing and Privileging.  The training specified in this policy shall be part of the Area and local facility credentialing and privileging policies for physicians, physician assistants, and advanced practice nurses conducting sexual assault medical forensic examinations.
  4. Competencies.  The training specified in this policy shall be part of the competencies for registered nurses to conduct sexual assault medical forensic examinations and shall be addressed in Area and local facility policies.
  5. Minimum Number of Yearly Examinations.  Maintenance of competencies to perform examinations shall be addressed in local credentialing and competency procedures.  If a SAE has conducted no sexual assault medical forensic examinations over a 1-year period, methods for competency assessments may include completing a virtual clinical practicum, simulation training, repeating clinical skills training, or completing a sexual assault medical forensic examination observed by a forensically experienced SAE.
  6. Continuous Quality Improvement.  All facilities providing onsite sexual assault medical forensic examinations must have processes in place for continuous quality improvement review of all examinations conducted.

3-29.9  RESPONDING TO A SUBPOENA AND TESTIFYING IN COURT

When an IHS employee receives a subpoena, that employee shall immediately notify his or her supervisor and/or the facility CEO.

The supervisor and/or the facility CEO shall immediately consult with the OGC.


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