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KEY POINTS IN THIS CHAPTER

  • The first step in proper forensic documentation is assessing the patient and documenting observations.

  • Maintaining a chain of custody is key to establishing the validity of evidence.

  • Nurses must obtain consent from the victim for collection of evidence and photographs whenever possible.

  • Nurses can also contribute to evidence collection without compromising patient care.

  • The nurse may be called as a witness regarding any forensic case in which he or she is involved.

INTRODUCTION

Nursing practice interfaces with law in many diverse settings. Proper assessment is a major responsibility of every nurse and is the very basis for all documentation. A systematic assessment includes objective observations and physical findings, and subjective data based on patient perceptions/input. A nurse’s intuition may also play a part in the assessment and subsequent documentation of findings. A perceptive nurse may note problems that might otherwise be missed (Lynch, 2011). In addition, all data has to be documented objectively, clearly, and appropriately.

Much has been written about the importance of healthcare professionals helping the legal system by having a basic understanding of guidelines for evidence collection. Due to the type of patients who present in emergency departments as well as other areas in the healthcare setting, clinical nurses often care for victims of violence (McCracken, 1999; Randall, Colman, & Rowe, 2011). Regarding assessment for victimization, a multitude of instruments are available to measure self-harm, interpersonal violence, and child abuse. However, even though many valid and reliable tools and resources are available, this does not mean they are used in practice (Bond & French, 2010). For this reason, it’s important that nurses take a leadership role in establishing guidelines for practice in which well-established tools are used in all areas of healthcare to screen for violence (Basile, Hertz, & Back, 2007b).

It’s the position of the Emergency Nurses Association that the emergency nurse (Ferrell, 2007):

  • Provides physical and emotional care to patients, and also helps preserve the evidentiary material collected in the emergency department

  • Collaborates with emergency physicians, social service, and law enforcement personnel to develop guidelines for forensic evidence collection, preservation, and documentation in the emergency care setting

  • Stays familiar with the concepts and skills of evidence collection, written and photographic documentation, as well as testifying in legal proceedings

This book provides many suggestions for how the nurse generalist can improve practice by learning some of the techniques of forensic science. This chapter explores the importance of collecting various types of evidence. In addition, the proper documentation of evidence and how the nurse may then be called upon to provide testimony in a case will be discussed.

OUTLINING THE TYPES OF EVIDENCE

Evidence, both testimonial and physical, involves data presented to ...

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