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.
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...
Explained in
- Forensic Nursing Documentation StandardsThe structured documentation completed by a Sexual Assault Nurse Examiner: triage, history in the patient's own words, systematic body map, specimen chain-of-c...