Injury documentation: Using the BALD STEP Mnemonic and the RCMP Sexual Assault Kit

Abstract

Injury assessment, nomenclature and documentation vary widely across emergency departments. The Royal Canadian Mounted Police (RCMP) has forensic laboratories across Canada and performs the majority of testing of evidence for Canadian victims of sexual assault outside of Ontario or Quebec. Most emergency nurses are familiar with the large box the RCMP officers bring for the documentation and collection of evidence after sexual assault. Fewer are familiar with the inner contents of the kit or documentation. The sexual assault kit and documentation are now undergoing change, with a new kit soon to be released. The RCMP forensic laboratories identified the need for kit changes due to equipment updates and research related to quality and best practices. Some health care professionals across the country and representatives of Making a Difference Canada were consulted for suggestions on documentation and kit contents. Mount Royal University’s Forensic Research Network (www.mtroyal.ca/forensicresearch) will be developing free educational materials on the kits and use of contents in preparation for the release of the new kits (hoped to be late 2011, but not yet determined). In the meantime, the focus of this article is to introduce emergency nurses to a few key changes in documentation and evidence collection they may anticipate. The largest of these changes is the adoption of a mnemonic phrase to aid in standardization of injury documentation and assessment known as BALD STEP.