When documenting an incident involving a sexual assault, what should the EMT do?

When documenting an incident involving a sexual assault, what should the EMT do?

• A. Avoid speculation and document only factual data.
• B. Include the results of the internal vaginal exam.
• C. Theorize as to why the sexual assault occurred.
• D. Include a description of the suspected perpetrator.

Answer: (A)

In an incident involving a sexual assault, the EMT's documentation must prioritize objectivity and factual accuracy. Documenting only factual data means recording observable events, actions taken, statements made by the patient, and any relevant physical findings without including personal opinions, assumptions, or interpretations. This approach helps ensure that the documentation is legally defensible and suitable for potential use in court, minimizing the risk of bias or misrepresentation. Choosing to include the results of an internal vaginal exam, theorizing motives behind the assault, or describing a suspected perpetrator introduces elements that can compromise the integrity of the report. Medical documentation in these sensitive situations must be clear and focused on what can be substantiated through direct observation and patient statements, maintaining professionalism and accuracy throughout the narrative.

In an incident involving a sexual assault, the EMT's documentation must prioritize objectivity and factual accuracy. Documenting only factual data means recording observable events, actions taken, statements made by the patient, and any relevant physical findings without including personal opinions, assumptions, or interpretations. This approach helps ensure that the documentation is legally defensible and suitable for potential use in court, minimizing the risk of bias or misrepresentation.

Choosing to include the results of an internal vaginal exam, theorizing motives behind the assault, or describing a suspected perpetrator introduces elements that can compromise the integrity of the report. Medical documentation in these sensitive situations must be clear and focused on what can be substantiated through direct observation and patient statements, maintaining professionalism and accuracy throughout the narrative.