SANE Examination Record
Definition
The structured documentation completed by a Sexual Assault Nurse Examiner: triage, history in the patient's own words, systematic body map, specimen chain-of-custody log, and follow-up plan.
- Sections
- Triage, patient history, body map, specimen log, follow-up plan
- History format
- Patient's own words
- Chain-of-custody
- Documented for every specimen collected
- Author
- Sexual Assault Nurse Examiner
Common questions
Why does the record specifically capture the patient's history in their own words rather than paraphrased?+
Verbatim wording preserves the patient's account without the examiner's interpretation layered in, which matters both clinically and legally since paraphrasing can unintentionally introduce assumptions that a defence attorney could challenge later.
How does the body map section function differently from the narrative history?+
The body map provides a standardised visual record of injury location and type independent of the verbal account, so it can corroborate or, in some cases, appear inconsistent with the narrative, both of which are relevant to the overall clinical and legal picture.
Why is the chain-of-custody log embedded directly in the exam record rather than kept separately?+
Keeping the collection, handling, and transfer log attached to the same record that documents what was collected and from where reduces the chance of a gap or mismatch that could later be challenged as breaking the evidentiary chain.
Related terms
- Addendum
- A separate, dated, and signed entry added to an existing record to correct an error or supply omitted information. It preserves the...
- Contemporaneous Record
- Notes made at or very close to the time of the event they describe. Courts give contemporaneous records more weight than later...
- Interpretive Language
- Words that assign cause, meaning, or legal category to a finding. Phrases such as 'consistent with sexual assault' or 'defensive wound' are...
- Objective Documentation
- Recording only what can be directly observed, measured, or quoted, without inference about cause, intent, or legal category. The nurse's role is...
- Verbatim Quote
- The patient's exact words, enclosed in double quotation marks and attributed to the patient, rather than the nurse's paraphrase or summary of...