Health Sector Response to GBV

National Guideline on providing care and prevention For Health Care Providers 73

Annexure 2

Medico legal Record Adapted from WHO Document Clinical management of Rape
Survivors

(To be used for providing a report on adults and children)

Confidential
Name of the Hospital …………………………………………….

MLC No.

Hospital No.

General Information
Name

Address Temporary: Permanent:

Brought /Referred Name: Address :

by :
Self/Police/Parent
/………………………..
Sex Date of Age
birth:
ID card
number:
Marital status Married /Separated /Widowed
Date and Time of
Examination
In the case of Name and address of the In the presence of(If Signature
Children parent /Guardian applicable)
(particularly when the Name ………………………………….. …………………………………………
history is given by this …………………………………………….
person )
About the incident
Date of incident Time of
incident
Description of the
incident
(in survivor’s
words) *

Physical Violence Yes No Details

Type
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National Guideline on providing care and prevention For Health Care Providers

Physical/Sexual
etc.
Use of restraints
Drugs/alcohol
involved
Penetration Yes No Details
Penis
Finger
Other
Ejaculation
Condom Used
After the incident Yes No details
Did the survivor
Vomit
Urinate
Rinse Mouth
Have a wash /
bath
Change clothing
Medical History
Contraception use
Menstrual History
Last Regular Was she menstruating at the Yes /No
Menstrual Period time of incident
Evidence of Number of weeks Pregnant
Pregnancy
Obstetric History
Summary
History of prior consenting intercourse
Only if samples have been taken for DNA Analysis
Last consenting intercourse if Date
within one week
Existing Medical conditions
Allergies
Current medications (if any)
Vaccination Tetanus Hepatitis B
HIV Status Known Yes /No Unknown
Medical Examination
Appearance (Clothing, Hair obvious physical or mental disability …)

Mental State as perceived by (Crying, anxious, agitated, depressed, depressed, cooperative etc.)
the examiner

Weight: Height: Pubertal Stage

Pre pubertal/pubertal/Adult
Pulse: Blood Pressure: Respiratory Rate: Temperature:
Physical Findings(Use the body maps attached)
Describe systematically, and draw on the attached body pictograms, the exact location of all wounds, bruises,
petechiae,marks, etc. Document type, size, color, form and other particulars. Be descriptive, do not interpret the
findings.
Head & Face : Mouth & Nose:
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National Guideline on providing care and prevention For Health Care Providers 75

Eyes Ears: Neck:

Chest : Back :

Abdomen : Buttocks:

Arms &Hands: Legs & Feet:

Genital & Anal Examination(Use the body maps attached)

Vulva in females /Scrotum in males: Introitus and Hymen

Vagina in females /Penis in males: Cervix:

Anus: Bimanual/ Recto vaginal Examination:

Position of survivor (supine, prone, knee-chest, lateral, mother’s lap:)

For Genital Examination: For Anal Examination :

Investigations Done
Name of examination Examined /Sent to Laboratory Result (if available)

Evidence Taken
Type and location Send to / Stored at Collected by / on …….(date)

Treatment Prescribed
Treatment Given Not Type and Comments
given
STI Prevention:

Emergency Contraception:
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National Guideline on providing care and prevention For Health Care Providers

Wound care :

Tetanus Prevention :

Other ( Specify) :

Other Services ,including referrals and arrangement for follow up :

General psychological emotional status as perceived by the examiner :

Details of Counseling /befriending provided :

Referrals for in-depth counseling (if done )

Follow up offered :
Accepted /Not
If yes date of next visit

Summary of the medico legal examination (The absence of lesions should not lead to the conclusion that no
sexual attack took place)

Certificate prepared on this day and handed over to the person concerned as proof of evidence.
Name of the Health professional conducting the
examination :
Designation :

Date :

Time:

Signature :

Name of the person to whom the report was handed

over :
Designation and Signature :

* If the survivor is a child, also ask:

Has this happened before?
When was the first time?
How long has it been happening?
Who did it?
Is the person still a threat?
Also ask about bleeding from the vagina or the rectum, pain on walking, dysuria, pain on
passing stool, signs of discharge, any other sign or symptom.