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OUR GOALS It is the genuine hope of the authors that, after reading this publication, users will have reaped the following benefits: � Improved technical understanding: By becoming more familiar with the child protection medical terminology and examination, members of the medical and legal community will have a stronger grasp of the information contained within the medicolegal certificate, reducing the possibility of misinterpretation. � Ability to “speak the same language”: Child abuse occurs globally; hence, physicians must share a single vocabulary so as to better communicate ideas and best practices worldwide. � Standardized procedures: The standardization of terminology and the certificate itself may lead to standardized procedures. If one comprehensive examination can be created and agreed upon by all members of the medico-legal community, there will be less cause for multiple exams and, thus, less possibility of re-traumatizing patients. Ultimately, it is our intention that this publication will serve as both an educational tool for child protection professionals unfamiliar with the medico-legal examination, and as a guideline for those in the medical community actually performing the examination. Please note that this manual is not intended to be a substitute for actual child protection specialist training. HOW TO USE THIS GUIDE This publication serves as a supplement to the standardized medico-legal certificate. On the following pages, the certificate will be dissected and explained in detail in order to clarify any areas of confusion and, ultimately, to facilitate its use by physicians and members of the legal community. Each section and subsection of the certificate is illustrated, complete with brief instructions for proper completion of that section. When further explanation is required, more detailed information is provided on the page, below the relevant section. The diagnosis of sexual abuse should not be based solely on the physical examination. In addition to the medico-legal exam, diagnosis depends heavily upon the results of the patient interview, behavioral assessment and laboratory tests. Further, medical evidence is o<strong>nl</strong>y one component of the overall criminal investigation of child abuse cases; other aspects such as crime scene investigation and witness corroboration by law enforcement investigators, and home visits conducted by social workers, are equally as important.
MEDICO-LEGAL CERTIFICATE DEMOGRAPHIC DATA PATIENT’S NAME AGE DOB SEX PATIENT’S ADDRESS CIVIL STATUS OCCUPATION NATIONALITY REQUESTING PARTY PLACE, TIME AND DATE OF EXAMINATION � Acute Evidentiary Examination (within 72 Hours of incident) � Non-Acute Examination FINDINGS GENERAL PHYSICAL FINDINGS HEIGHT WEIGHT GENERAL SURVEY MENTAL STATUS PERTINENT PHYSICAL FINDINGS/ PHYSICAL INJURIES EXTERNAL GENITALIA URETHRA AND PERIURETHRAL AREA PERIHYMENAL AREA AND FOSSA NAVICULARIS HYMEN PERINEUM DISCHARGE INTERNAL AND SPECULUM EXAMS ANAL EXAMINATION FORENSIC EVIDENCE AND LABORATORY RESULTS ANO-GENITAL EXAMINATION DIAGNOSTICS AND EVIDENCE GATHERING IMPRESSIONS
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Ipce Newsletter E 17 I p c e N E W
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Ethics and ... Ethics The guideline
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The MMWR series of publications is
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