a forensic medical examination Patient identification/appearance 90 440 Non-genital anatomy 96 470 Genital anatomy 92 451 Medical conditions 32 155 Pre-existing injuries 46 223 Normal variants and birthmarks 28 135 Tattoos and piercings 27 132 Clothing and trace items 2 9 66 Photodocumentation Practices Photodocumentation was a common community based standard of care during forensic medical examinations for the majority of respondents (84%, n=471). Similarly, 87% (n=491) reported photodocumentation as part of their individual practice when completing forensic medical examinations. The 72 respondents (13%) reporting photodocumentation was not part of the forensic medical examination skipped to the demographic questions. Unfortunately, data was not collected related to age of patients served for respondents not using photodocumentation. However, 49 respondents not using photodocumentation during forensic medical exams provide services for patients reporting sexual abuse/assault examinations. An additional 22 respondents who were not engaging in photodocumentation practices reported providing forensic medical examinations for all forms of injury, abuse, neglect or harm. All respondents identified forensic medical photodocumentation as a purpose for collecting images during forensic medical examinations (100%, n=487) with a large number also selecting evidence for law enforcement (81%) as a purpose for collecting images (Table 2). The most common images collected included patient identification or presentation and non-genital and genital anatomy (Table 2). Of the respondents providing services to prepubescent children, 87% collect images of non-genital anatomy and 95% collect images of anogenital anatomy. As expected, a larger number of respondents provide services to adolescents, adults and older adults (Table 2). Unlike services to prepubertal children, non-genital and genital images are equally collected (91%) during forensic medical examinations of adolescents. Respondents serving adults and older adults are slightly more likely to collect images of nongenital anatomy (93%, n=417; 93%, n=401 respectfully) than images of ano-genital anatomy (91%, n=410; 90%, n=391, respectfully). 67 One-third of the respondents (n=162) experienced an occasion when they decided NOT to take pictures during a forensic medical examination/evaluation. Reasons included the patient declining to be photographed (91%, n=148), equipment unavailable or not working (47%, n=76), the forensic nurse decided images were not needed (22% n=36), and patient discomfort (3%, n=5). Interestingly, 65 respondents (13%) reported they would use their personal cell phone or other personal device to capture images if their normal equipment was malfunctioning or not available. Collection, Storage, Security and Transfer of Digital Images The majority of respondents (94%) use some type of digital technology to capture images (see Table 3). The most common type of technology used to capture digital images was a digital camera (85%, n=416). Three reported using a non-digital device (e.g., disposable camera), and 27 (6%) used both non-digital and digital devices. Over half of the respondents (53%) reported that access to stored images was tracked or monitored either electronically or manually. However, 21% (n=101) reported no tracking or monitoring mechanisms in place for accessing images and 26% (n=128) did not know if access to images was tracked or monitored. Table 3 also reflects the types of images collected by respondents during a forensic medical examination/evaluation, storage of these images, and how images were protected from unauthorized access. Once stored, the forensic nurse completing the exam may retain access to the images (65%, n=316). In contrast, program administrators or coordinators may have access (76%, n=369) or the entire forensic team may have access (27%, n=132). Almost half of respondents transfer images via a portable storage device person-to-person (47%, n=230) with a small number (12%) printing and physically delivering printed images or using electronic 68 transmission (e.g., electronic file share) (9%). Approximately 11% reported not knowing how images were transferred to other persons or agencies. Table 3: Collection, storage, security and transfer of digital images collected during the forensic medical exam Variable Percent n Digital technology used for photodocumentation Digital camera only 64 312 Colposcope only 14 66 Digital camera & colposcope 17 82 Video camera only 1 4 Combination of digital camera and devices other than colposcope 4 22 Storage of digital images With electronic medical record (EMR) 19 94 Secure network separate from EMR 35 170 Computer or external hard drive 12 58 Disc or other portable media (e.g., jump drive) 31 149 Digital images are not stored or don’t know 3 17 Protection of images from unauthorized access Password protection 56 264 Software encryption 30 144 EMR security 8 40 EMR security plus additional measures 18 87 Printed, erased, and physical secured 17 81 Digital storage media physically secured 9 45 With physical (hardcopy) record 4 18 Don’t know 9 41 Transfer or release of images to other persons or agencies Portable storage device person-to-person 47 230 Images printed and