Is Electronic Documentation More Effective Compared to Paper Documentation for SANE Examinations?

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Forensic nursing is a multi-disciplinary field that encompasses medical and legal aspects. The role of the sexual assault nurse examiner (SANE) is to provide medical care and perform a forensic examination on the victim. The findings of the SANE assessment must be documented according to A National Protocol for Sexual Assault Medical Forensic Examinations from the Department of Justice. The purpose of this project is to assist the proposed facility with transitioning to electronic documentation to eliminate the issues associated with paper documentation. These issues include the legibility of handwriting, the risk for fire to destroy all paper records, the potential for a breach in the Health Insurance Portability and Accountability Act (HIPAA), and the accessibility of documents to the court system. The court system can only subpoena electronic records, making it difficult to prosecute on sexual assault cases. The forensic nurse collaborated with the information technology (IT) department and emergency department leadership team. An outside facility was examined to assess the transition to electronic charting. Assessment data for electronic charting was considered for the proposed facility. The IT department designed an electronic version of the paper documentation and is set to roll out in the Spring of 2023. All SANEs will be trained and then assessed for data collection. A scale system of 1-5 will determine the end users’ comfort level with the system. Ongoing communication with local attorney offices is taking place to assess the outcome of this project. Additionally, transitioning to electronic documentation has eliminated the legibility of handwriting, the risk of fire to destroy records, and the potential for a HIPAA violation. Moreover, the access to sexual assault documentation has increased for the court systems, deeming an effective approach to strengthen prosecution rates.