Examination Process- Discharge and Followup



Download this section- Discharge and Followup

Recommendations at a glance to facilitate discharge planning and follow-up with patients:

  • Address issues related to medical discharge and follow-up care.
  • Advocates, law enforcement representatives, and other involved responders can coordinate with health care providers to discuss a range of other issues with patients prior to discharge

Health care personnel have important tasks to accomplish prior to discharging patients, as do advocates and law enforcement representatives (if involved). These responders should coordinate their activities as much as possible to reduce repetition and avoid further overwhelming patients.

Address issues related to medical discharge and follow-up care.

Health care personnel (preferably examiners) should address the following issues with patients prior to discharge:

Make sure patients’ medical and mental health needs related to the assault have been addressed. Discuss with patients whether they have any other medical and/or mental health concerns related to the assault.1 If injuries or trauma have not been treated yet, examiners should refer patients to exam facility clinicians (e.g., hospital emergency department staff) for care or provide the appropriate community referrals prior to discharge.

Provide patients with oral and written medical discharge instructions. Include a summary of the exam (e.g., evidence collected, tests conducted, medication prescribed or provided, information provided, and treatment received), medication doses to be taken, follow-up appointments needed or scheduled, and referrals. The discharge form could also include contact information and hours of operation for local advocacy programs.

Arrange follow-up appointments for patients. Follow-up may be indicated to document developing or healing injuries (for example, bruising) and complete resolution of healing. Forensic follow-up may also be indicated to further evaluate nonspecific findings (such as redness, swelling, or cervical abnormalities) that may be related to acute trauma or may be normal variants. (A jurisdictional policy describing the indications and procedures for follow-up for documentation purposes should be in place.) Appointments may also be needed to address ongoing medical concerns. If appointments are not scheduled, at least indicate to patients which appointments are needed and if sites are different than the initial exam. Make it clear that patients do not have to disclose the assault to receive follow-up medical care. Follow-up appointments may include:2

  • For patients with evidence of acute trauma: A short-term follow-up appointment to reexamine and document the development of visible findings and photograph areas of injury; and an exam 2 to 4 weeks later to document resolution of findings or healing of injuries.
  • For all patients: Repeat exams for STIs according to facility policy (see C.8. STI Evaluation and Care).
  • Primary health care providers or other nonacute care providers can provide longer term care as needed (e.g., for HIV testing, STI testing, and administering doses of Hepatitis B vaccine).

Discuss follow-up medical contact procedures. Discuss with patients whether they would like health care providers to provide a follow-up call and, if so, the best method and time for this contact (maintaining patients’ privacy and safety). The main purposes of such a call are to check on medical status and remind patients about the necessity of follow-up testing and care. An optimal time for a first medical follow-up contact is 24 to 48 hours following discharge. Personnel following up with patients should be familiar with the case, confidentiality issues, and potential medical needs.3

Advocates, law enforcement representatives, and other involved responders can coordinate with health care providers to discuss a range of other issues with patients prior to discharge.

Involved responders should come to agreement about who is responsible for each step below and where coordination is necessary. For example, while advocates usually explain advocacy services and law enforcement representatives explain the investigative process, each responder may have a role in helping patients plan for their safety and well-being. If health care personnel are the only responders involved, however, they may need to provide patients with much of the information below.

After the exam is finished, address patients’ physical comfort needs. (For a discussion of this topic, see A.2. Victim-Centered Care.)

Help patients plan for their safety and well-being. Jurisdictional and exam site policies should be in place to facilitate this process. Assist patients in developing a postexam plan that addresses their physical safety and emotional well-being. Screen for domestic and dating violence and others forms of abuse. Assist patients in considering things such as:

  • Where are they going after being discharged? With whom? Will these individuals provide them with adequate support? Is there anyone else they would like to contact? (Provide information about available community resources for obtaining support and help in making the contact if needed.)
  • Will their living arrangements expose them to the threat of continued violence or harassment? Is there a need for emergency shelter or alternative housing options? (Provide options and help obtain if needed.)
  • Are they eligible for protection orders? (Provide information and help obtain if desired.)
  • Is there a need for enhanced security measures? (Discuss options and help obtain if desired.)
  • If they feel unsafe, what will they do to get help? (Discuss options and help them develop a plan.)

Planning must take into account the needs and concerns of specific populations. For example, if patients with physical disabilities require shelter, the shelter must be accessible and staff able to meet their needs for personal assistance with activities of daily living.4 If patients living in institutional settings have been assaulted by another resident, a staff person, or person who has easy access to residents, the institution should offer alternative living arrangements and reduce the likelihood that patients have to come into contact with the assailant again. It should also ensure them access to services designed to promote their recovery.

Explain follow-up contact procedures of all responders involved. Coordinate follow-up contact of involved agencies as much as possible, keeping the number of responders contacting patients to a minimum. Explain if contact procedures are different for patients with limited English proficiency or specific communities or institutions (e.g., schools, military bases, prisons, or residential programs may have their own procedures). Consider offering patients prepaid phone cards they can use to call a contact person with concerns or questions.

Explain advocacy and counseling services. Sexual assault advocacy programs typically offer a host of services for victims and their significant others, in addition to those provided during the exam process. (For more information on services, see A.2.Victim-Centered Care.) Advocates can describe and offer patients, their family members, and friends these services, as well as explain options for counseling in the jurisdiction and offer referrals. Some advocacy programs provide professional mental health counseling, but many refer patients to community or private agencies. Before being discharged, advocates should ask patients if they can follow up with them. If they agree, they can determine optimal methods and times for the contacts. During follow-up contacts, advocates can help patients reassess their safety; offer support and crisis counseling; answer their questions and provide additional referrals and information; and help coordinate other advocacy services and counseling based upon identified needs.

Explain the investigative process. If law enforcement is involved, inform patients that investigators will request an interview with them, if not already done, explain the criminal justice process and victims’ rights, reassess their safety and provide assistance as warranted, and then recontact them as needed as their case

progresses.5 Explain if contact procedures are different for patients with limited English proficiency or for specific communities or institutions. Patients should receive contact information of involved law enforcement representatives and agencies and a case report number. They should feel free to call their investigator with any new relevant information, if new signs of injuries appear, about suspects’ compliance with protection orders or bond conditions, if suspects try to contact them, or with other related questions or concerns. They should be aware that they will be contacted by the prosecution office if their case goes forward. (Patients should be aware that it is their decision whether to report their case and talk with law enforcement officials and prosecutors.)

If evidence has been gathered and law enforcement is involved, the law enforcement representative can discuss with patients the possibility of a match being found through DNA analysis or of other victims of the same assailant being identified. Ask patients if they want to be contacted by law enforcement in these situations and, if so, determine the best contact method.

For patients who have not made a report and when law enforcement is not involved, patients should be given information on who to contact and how if they decide that they do want to make a report. They should also be given information on where the kit will be stored and how it will be tracked (for example if there is a tracking number, it should be provided).

Provide information. Offer patients clear and concise information, both orally and in writing.6 Information should be tailored to patients’ communication skill level/modality and language. (For more information on the types of information that patients might find useful, see A.2. Victim-Centered Care.)

 

 Table of Contents Examiner Court Appearances

1 Care should be taken to ensure that mental health professionals can appropriately and respectfully handle patients from minority and/or stigmatized groups such as specific cultural groups or transgender individuals.

 

2 Bullets drawn partially from the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 98.

 

3 When appropriate, advocates may assist health care personnel in encouraging patients to seek the follow-up medical care they need. They also may encourage patients to discuss with health care providers their concerns about initial and follow-up medical care.
4 Drawn from M. Nosek and C. Howland, Abuse and Women with Disabilities, 1998, p. 3.
 5 Some patients may want information, either during the exam process or after, about the amount of time it takes to process cases in the criminal justice system. It can be helpful for them to know the range of time it typically takes in that jurisdiction for evidence to be analyzed and for cases to be forwarded to prosecution or tried in court. This information may help them prepare for their justice system involvement. At the same time, they must understand that every case is different and typical time estimates from the past may not apply.

 

6 Many local sexual assault advocacy programs and state coalitions of sexual assault programs offer publications that speak to victims’ concerns in the aftermath of an assault. However, any involved agency, SART, or coordinating council could develop such literature.