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Discipline

: Emergency

Sub Discipline

: Emergency

Document Title

: OSCC Sexual Assault Clerking Note

OSCC TEAM

OSCC Team

PERSONAL DETAILS

Telephone

Please Update Method

Religion

Occupation

Monthly Income

Education

Marital History

Duration Of Marriage

Number Of Children

Male

Female

Date Of Arrival

Time Of Examination

Place Of Examination

Police Report

No

Accompanying Person(s)

Please Update Method

HISTORY OF THE INCIDENT

Present Incident

Date

Time

Location

Place

Town

Street

Circumstances That Led To The Incident (History)

Is Force/Violence Was Used?

Yes, specifyNo

Type of force used

Blows

Slaps

Punch

Kicks

Strangulation

Weapons

Others, specify

Was Any Weapon Used By The Assailant?

Yes, specifyNo

Type of weapon used

Gun

Knife

Blunt Instrument

Sharp Pointed Instrument

Others, specify

Did The Patient Put Up A Resistance?

Was The Patient Restrained?

Yes, specifyNo

Were Any Drugs Used?

Yes, specifyNo

Was Any Alcohol Used?

Yes, specifyNo

Other Relevant History

Identity Of Assailant

How Many Assailants?

Is Assailant Known To Patient?

YesNo

Relationship

DETAILS OF ACT

Type Of Sexual Act

Oral

YesNoUncertain

Vagina

YesNoUncertain

Anal

YesNoUncertain

What Was Used

Finger

YesNoUncertain

Penis

YesNoUncertain

Other objects, specify

Other objects, specify

No

Condom Used

YesNoUncertain

Lubricants Used

YesNoUncertain

Did The Patient Experience Any Pain?

Yes, specifyNo

Was There Any Bleeding?

Yes, specifyNo

Other Symptoms

History of events after the incident :

Please Update Method

Menstrual History

Last Menstrual Period (LMP)

Menarche

Cycle

RegularIrregular

Flow

Interval

Obstetric History

Parity Index

Gravida

Para

Abortion

Date Of Last Child Birth

Contraception

Contraception

YesNo

Method

Barrier

Sexual History

Past Experience Of Sexual Intercourse

YesNo

Previous Masturbation

YesNo

Medical History

Medical History

Immunization History (if a child)

CompleteNot completeUncertainNot applicable

Last Toxoid/Att Date

Surgical History

Surgical History

Please Update Method

DEVELOPMENTAL HISTORY (IF A CHILD)

Developmental History (if a child)

Plan

SIGNATURE (DOCTOR PAEDIATRIC)

PHYSICAL EXAMINATION

General Appearance

VITAL SIGNS

Vital Signs & Other Observations

Pupils

General Condition and Examination

General Condition

Good

Behaviour

Calm

Clothing

Please Update Method

General Build (Does It Correspond To Victim Age?)

CorrespondsBiggerSmaller

Gait

NormalAbnormal

Physical Examination Findings

Secondary Sexual Characteristic

Is There Any External Bruise/Abrasions/ Cuts/ Laceration ?

YesNo

Collection of Forensic Samples

Please Update Method

Collection of clothes

Indicated

Type of Clothes

Please Update Method

Total No. of Samples

Please Update Method

Samples Handed Over To Police Officer

Samples Labelled & Packed by

Name

Designation

Ic No

Handed Over By

Name

Designation

Ic No

Received By

Name

Rank No

Police Station

TREATMENT AND AFTER CARE

Orders

Referral

Outgoing Referrals

SIGNATURE (BY ETD DOCTOR)

GYNAECOLOGICAL EXAMINATION

Vulval Examination

Normal

Atrophic

Warty growth

Varicose veins

Leukoplakia

Bartholins abscess

Bartholins cyst

Laceration

Lax perineum

Ulcers

Others, specify

Vaginal Examination

Normal

Discharge present

Inflamed

Atrophic

Tight introitus

Stenosis

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Injuiry

Intact hymen

Old torn hymen

Fresh torn hymen

Obliterated

Ulcerated

Sign of haemotocolpos

Septum

Others, specify

Vulva

Please Update Method

Record Tear

Hymen Intact

Intact

Do not proceed for further vaginal examination

Take smear from introitus

Do rectal examination

Torn

Specimen Examination

Vagina

Cervix

Take smears

Bimanual Examination

Vagina

Cervix

Uterus

Fornix

Cervix

Cervix Position

AxialAnteriorPosterior

Cervix Size

NormalAbnormal

Cervix Status

NormalAbnormal

Cervix Contact Bleeding

NormalAbnormal

Cervix Tenderness

YesNo

Cervix Prolapse

YesNo

Cervix Comment

Uterus

Uterus Position

NormalAbnormal

Uterus Size

NormalAbnormal

Uterus Regularity

NormalAbnormal

Uterus Consistency

NormalAbnormal

Uterus Tenderness

NormalAbnormal

Uterus Mobility

NormalAbnormal

Uterus Comment

Other

Adnexae Examination

Normal

Enlarged Right Ovary

Enlarged Left Ovary

Fixed mass right

Fixed mass left

Tender right

Tender left

Others, specify

Other Findings

Examiners Finding

Are there any body injuries?

YesNo

Do these injuries indicate force has been used on patients?

YesNo

Can you specify the type of violence used?

YesNo

Are there any genital injuries?

YesNo

Do the genital injuries indicate?

YesNo

Sign of blunt object penetration of the vagina?

YesNo

Are there acute injuries?

AcuteNon AcuteBoth

Is the history given consistent with examination findings?

YesNo

Are there any signs of abuse/torture?

YesNo

Does the patients physique correspond with his/her age?

YesNo

Are there any mental abnormalities?

YesNo

Is the patient mentally retarded?

YesNo

Are there any signs of intoxication?

YesNo

COLLECTION OF FORENSIC SAMPLES

Collection of Forensic Samples

Please Update Method

Samples for Baseline UPT and STI

Please Update Method

Samples Handed Over To Police Officer

As Above

As Above

Samples Labelled & Packed by

Name

Designation

Ic No

Handed Over By

Name

Designation

Ic No

Received By

Name

Rank No

Police Station

Plan

SIGNATURE (DOCTOR O&G)

SODOMY

Collection of Forensic Samples

Please Update Method

Total No. of Samples

Please Update Method

Samples Handed Over To Police Officer

As Above

As Above

Samples Labelled & Packed by

Name

Designation

Ic No

Handed Over By

Name

Designation

Ic No

Received By

Name

Rank No

Police Station

Plan

Genito-Anal Examination

Urethral Examination

Rectal

Inner Thigh

Finding PresentNo Findings

External Genitalia

Finding PresentNo Findings

Perineal Area

Finding PresentNo Findings

Rectal Examination

Anus / Anal Canal

Scratches

Muscle Tear

Fecal Staining On Buttocks

Swelling

Anal Sphincter

Muscle Tone

GoodLoose

Examiners Finding

Are there any body injuries?

YesNo

Do these injuries indicate force has been used on patients?

YesNo

Can you specify the type of violence used?

YesNo

Are there any genital injuries?

No

Do the genital injuries indicate?

YesNo

Sign of blunt trauma?

YesNo

Are there acute injuries?

AcuteNon AcuteBoth

Are there any anal injuries?

YesNo

Do the anal injuries indicate

YesNo

Sign of blunt object penetration into the anus?

YesNo

Are they acute injuries?

YesNo

Is the history given consistent with examination findings?

YesNo

Are there any signs of abuse/torture?

YesNo

Does the patients physique correspond with his/her age?

YesNo

Are there any mental abnormalities?

YesNo

Is the patient mentally retarded?

YesNo

Are there any signs of intoxication?

YesNo

SIGNATURE (DOCTOR SURGERY)

PRELIMINARY REPORT

As Above

As Above

Police Report Number

Police Station

Police Officer Information

Please Update Method

Doctor(Who Gave The Report)

Please Update Method

Preliminary Report

SIGNATURES

Notes Component

OSCC TEAM
PERSONAL DETAILS
HISTORY OF THE INCIDENT
DETAILS OF ACT
DEVELOPMENTAL HISTORY (IF A CHILD)
SIGNATURE (DOCTOR PAEDIATRIC)
PHYSICAL EXAMINATION
VITAL SIGNS
TREATMENT AND AFTER CARE
SIGNATURE (BY ETD DOCTOR)
GYNAECOLOGICAL EXAMINATION
COLLECTION OF FORENSIC SAMPLES
SIGNATURE (DOCTOR O&G)
SODOMY
SIGNATURE (DOCTOR SURGERY)
PRELIMINARY REPORT
SIGNATURES

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