This Forensic Nurses Week, we’re talking about ways to make our practices better. The last couple days have focused on individual performance. Today, let’s talk about program performance…

The expert at trial should never be the first person to review our record of the patient encounter.

But that’s exactly what happens when a forensic nursing program has no formalized quality improvement process in place. And that’s a problem–because it means the program has set no benchmarks for what constitutes optimal performance. If there are no benchmarks for quality, how can a forensic nurse know if they’re doing a good job? How can they grow in their clinical capacity? How can the program hope to effectively (and sustainably) expand their program to other patients?

As we wrote for the SANE Sustainability project:

Every SANE program should have a process for regularly reviewing patient care and clinician performance. Having such a process means that the program has set specific and achievable benchmarks for quality. Programs that have a plan in place often center that plan on quality assurance initiatives, which are an appropriate initial step. But programs should strive to incorporate a quality improvement process for sustainability. Quality assurance focuses on the individual and addresses a problem or deficiency that has already occurred; quality improvement is systems-focused and is proactive, done with the intention of making changes to prevent future issues from occurring. Some aspects of a quality process can serve a dual role: chart review, for example, allows for both quality assurance (e.g. making sure that documentation is complete for every patient seen in the program) and quality improvement (e.g. noting that multiple clinicians appear to have issues obtaining clear photos at close-range). Peer review also can serve both functions, bringing to light issues with individual documentation or interpretation of findings, but also serving as an educational opportunity that informs the clinical knowledge of all participants.

You can read the full piece on the NSVRC website. It’s full of resources and suggestions for implementation. (And if you still haven’t downloaded the app, get it here).

This should not be an optional program component. I have never talked about creating a defensible practice (one that can withstand vigorous scrutiny on cross examination) and not discussed the importance of a quality process. Program managers should fight for paid time in their schedules to implement and conduct quality improvement activities. Forensic nurses in programs without quality improvement processes should strenuously advocate for them. Medical Directors should step up and participate, as well–your voices are needed as one aspect of an effective quality process. And if you already have a process in place, talk about how it’s working with other program managers who are struggling to make this happen. Quality improvement processes benefit professional growth, efficacy of witness testimony, and most importantly, patient care.

Tomorrow, we wrap up the discussion of improving our profession with a look ahead. What’s next for us?

Because it’s Forensic Nurses Week, we’re focusing on ways to improve practice. Today, let’s talk about documentation.

Want to know my one wish for better medical-forensic documentation? Three words: review of systems (ROS). Seriously–hear me out on this.

In order to improve documentation, it’s critical to consider its purpose. We don’t document our encounters in anticipation of trial. We document because it’s the standard of practice for any healthcare encounter, forensic or not. We document because we aren’t going to be the last person to care for this patient. Everyone benefits from picking up where the last guy left off rather than starting from scratch each time (an argument for why medical-forensic records should be available to other healthcare providers, but that’s another post).

So why am I so enamored with ROS? Because it forces us to think about the entire patient, not just the most likely sites of injury or the areas that get swabbed; because it allows us to consider concomitant health issues with which our patients present, ones we can address while they’re with us.* And since we were talking about differential diagnoses yesterday, let’s keep in mind that completing a ROS with every patient often allows us to better identify the most likely causes for the patients’ findings.

Why do I like to see it in records I review before trial? Because it’s harder to argue that the treating clinician is just a forensic technician or arm of the investigation when there is this type of comprehensive exam documented. It demonstrates a commitment to caring for the whole patient and not just focusing on where potential evidence may be found. I have no hard science to back this up, but my anecdotal experience is that programs that don’t conduct (and document) ROS with their patients are more likely to have other gaps in their exam process and documentation: missing vitals, health history, allergy information, suicide assessment, danger assessment, follow-up recommendations. Conducting a ROS means clinicians are more likely to subscribe to the notion that experiencing violence is a healthcare crisis, not just a crime.

Tomorrow, let’s talk about the one process program managers can implement to move our practices forward.

*Many of my patients don’t regularly access healthcare services, so it’s a shame to waste the opportunity to provide as much care as I am able to, simply from a public health perspective.

This week, because it’s Forensic Nurses Week, I’d like to talk about how we can keep getting better. First up: one way to generally improve our value to patients and the justice system simultaneously.

There’s a lot to really celebrate about the work we do in forensic nursing. But we still have areas upon which to improve. Often times our field is preoccupied with the legal aspects of the work, sometimes to the detriment of good patient care. There is an abundance of research that underscores just how extensively violence impacts health in both the short- and long-term. And yet so much focus is on evidence collection and the patient as “crime scene” (a completely unfortunate designation).

The best thing we could do to be better at this work, both in the exam room and in the courtroom would be to do everything in our power to improve our assessment skills. Participate in as many educational sessions as we can find on injury evaluation and general physical assessment; spend time with more experienced clinicians crafting comprehensive differential diagnoses for the injuries and infections we see. Not only will it mean better care for each patient who sees us (and appropriate anticipatory guidance prior to discharge), it will also mean that if we take the stand we can speak extensively to the clinical care of our patients, including what else could have caused the issues the patient had (and why we ruled out many of them). Why is that important? Because we are licensed nurses and our role is to provide healthcare, not investigate crime. Want to have the opportunity to tell a jury what the patient said about the assault? It’s a lot less likely to happen if our exam process sounds more like an extension of the investigation rather than a comprehensive healthcare encounter. Want to be the most credible witness possible? Make sure there is little room to attack testimony as biased.

On a related note, I don’t think it’s necessary to be an advanced practice clinician to be a good forensic nurse, but because of the autonomous nature of this work, we do have to develop some of those skills to be particularly proficient. That comes from flexing our assessment muscles (and the documentation muscles that go with it). Comprehensive patient assessments (with corresponding comprehensive documentation of those encounters) increase our efficacy in court. Because our job in court is to teach–not to get the “bad guy” and not to make the prosecution’s case.

I would submit that if we concentrate on enhancing our clinical capacity, patients will also benefit in the courtroom, but the inverse is definitely not true. If we focus on what could happen in the courtroom, patients’ healthcare will suffer. I see it over and over again when I review records and listen to clinicians testify.

Tomorrow, let’s discuss documentation– specifically the one thing that could universally improve medical-forensic record completeness.

Don’t forget we have a giveaway going on this week. See all the details here.

I taught a new session at IAFN this year, Evaluating the Treating Clinician’s Testimony: A Defense Expert Perspective. It was one of ten that was recorded, and it’s now available for purchase on the IAFN site. For $25 ($40 for non-IAFN members) you can check out the talk– 1.5 CEs are included in the fee. Find this, and all of the other recorded sessions here.

I wanted to address an issue that I heard repeatedly at the conference; one that has also been brought directly to me from FHO readers–injury documentation. There was a session in Denver where it was the focus, and before I go into the heart of things I want to start with this–this post is solely intended to add to the discourse, since that’s what helps move the profession forward.

Now, I was not in the session, but I heard from so many people who were there, I feel confident that I am accurately reflecting at least a bit of what has people talking: the notion that we shouldn’t document blood, but rather red fluid (or something to that effect), and we should not document bruise, but simply discoloration, and an appropriate descriptor. The reasons appear to stem from a cross-examination experience at a trial, where a nurse couldn’t speak to how she definitively knew blood was blood, and presumably, the same was true of the bruise (if I have any of this wrong, please correct me). Were I in this session, it’s possible I would have agreed with everything else the presenter said, but on these two points let me offer this:

1. We are clinicians, and as such, we assess patients. But we have to be able to describe the knowledge base that informs our capacity to do so. I feel fairly confident in my ability to identify blood–from its feel, its source (such as a wound out of which it is flowing); the way it appears after it has dried; the accompanying clinical signs, symptoms or history that support its positive identification, such as wounds, or pain, or a report of a traumatic event. You get where I’m going with this. I would question a clinician’s ability to definitively identify bleeding in the vaginal vault as menstrual blood, perhaps, but I wouldn’t challenge the blood part of it. Just the nature of that blood. The same is true for bruises: in general, I have been assessing them my whole career and I know what one looks like, that it is generally tender with palpation, often accompanied by a history of trauma, etc. The exception to that is when it’s the cervix–then I will call it discoloration, because many things can give the appearance of a bruise, but until I have the ability to assess the cervix on follow up, one of the things I can’t rule out is the possibility that that discoloration is normal for that woman.

2. I generally try and remain consistent in how I assess and document patients. Which means if I would use the terminology with other patient populations (read: primary care), I wouldn’t change it for the forensic one. I implement the same nursing process no matter the patient population, only the chief complaint and some of the tools and forms I use differ. The approach is generally consistent. I use blood and bruise for other types of patients; I’m probably going to use it for this patient population, too.

3. Perhaps one of the most important points: a tough cross-examination is not enough of a reason to change practice, but instead an opportunity to identify problems with your response. A nurse who can’t articulate why she knows something is blood shouldn’t just stop identifying blood, but get better at describing the information that supports its identification as such. This is true for much of what we do–there will be times when some aspect of our practice subjects us to pain on the stand, but most of the time, the 1st step should be to do the post-game analysis and see where we need to get better at our explanations rather than simply changing practice based on that single experience.

I’m certainly interested in people’s thoughts on this. There’s no single answer, so we can respectfully disagree. But if you do disagree, please help me understand where our opinions diverge so that all of us can engage in more thoughtful and constructive debate.